Form SSA-7004 "Request for Social Security Statement"

What Is Form SSA-7004?

Form SSA-7004, Request for Social Security Statement, is a form used to request information about the individual's earning history, estimates of their and their family members' eligibility for the Social Security benefits. It is also used for the estimation of taxes paid in Social Security. The most recent version of the Social Security Form SSA-7004 was issued by the U.S. Social Security Administration (SSA) on November 1, 2017. An SSA-7004 printable form is available below for download.

Alternate Names:

  • SSA Form 7004;
  • Social Security Statement Request Form.

The SSA mails the Social Security Statement annually to workers aged 60 and to those who do not receive Social Security benefits three years prior to their birthday. If an individual files Form SSA-7004, the mailing schedule will change. The Social Security statements will be sent annually after the date the request was processed.

File Form SSA-7004-SM, Request for Earnings and Benefit Estimate Statement, in order to have the SSA send you a record of your earnings and an estimate of your Social Security taxes, as well as estimates of benefits you and your family members may be eligible for. Use Form SSA-7004-SM-OP1, Request for Social Security StatementRequest the form by calling the SSA toll-free 800 number or by calling, writing, or visiting a local SSA office., in order to request a statement from the SSA electronic system.

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How to Fill Out SSA-7004 Form?

A Social Security Statement Request Form can be obtained from a local Social Security office, requested by phone or online via My Social Security account. Any person aged 25 and older who has a Social Security Number (SSN) can file the request.

The statement contains information about the benefits, the individual's eligibility for these benefits, and a description of the eligibility criteria. These benefits include retirement payments, disability benefits, and family survivors' payments. Also, the Statement contains eligibility for Medicare at the age of 65. The information provided in the request is used by the SSA to calculate eligibility and credits the individual has earned. The Social Security statement will be mailed within six weeks after the request was filed.

Please refer to the instructions below when filling out Form SSA-7004:

  1. Blocks 1 through 5 are self-explanatory. For Items 6 and 8, show only the earnings that are covered by Social Security.
  2. Provide the number of your actual earnings the previous year in Block 6A. Enter the estimated amount of earnings this year in Block 6B.
  3. Enter the age you plan to stop working in Block 7.
  4. Enter the average yearly income between the current year and the year you are planning to retire in Block 8. If you do not expect any changes, enter the number you entered in Block 6B.
  5. Indicate whether you want your Social Security Statement mailed to you or to another person or organization in Block 9. If you want the statement to be mailed to you, enter your mailing address. If you want the statement to be mailed to another person or organization, enter your name (with c/o) and the mailing address of the person or organization.
  6. Sign the form with your name, provide your daytime phone number and date the form. Mail the completed form to the Social Security Administration Wilkes Barre Data Operations Center P.O. Box 7004 Wilkes Barre, Pennsylvania 18767-7004.
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Form SSA-7004 (11-2017)
Discontinue Prior Editions
Page 1 of 3
Social Security Administration
OMB No. 0960-0466
Request for Social Security Statement
Within four to six weeks after you return this form, we will send you:
• a record of your earning history;
• an estimate of how much you have paid in Social Security taxes; and
• estimates of benefits you (and your family) may be eligible for now and in the future.
Please note: If you have received periodic Social Security Statements in the mail, this request may stop your
next scheduled mailing.
We hope you will find the Statement useful in planning your financial future. Remember, Social Security is more than
a program for retired people. Social Security is with you throughout life's journey. For example, it can help support
your family when you die and pay you benefits if you become severely disabled.
If you have questions about Social Security or this form, please call our toll-free number, 1-800-772-1213 (TTY
1-800-325-0778)
Please check this box if you want to get your Statement in Spanish instead of English.
Please print or type your answers. When you have completed the form, mail it to:
Social Security Administration
Wilkes Barre Direct Operations Center
P.O. Box 7004
Wilkes Barre, PA 18767-7004
1. Name shown on your Social Security card:
First Name:
Middle Initial:
Last Name only:
2. Your Social Security number as shown on your card:
-
-
3. Your date of birth
/
/
4. Other Social Security numbers you have used:
-
-
-
-
5. Your Sex:
Male
Female
Form SSA-7004 (11-2017)
Discontinue Prior Editions
Page 1 of 3
Social Security Administration
OMB No. 0960-0466
Request for Social Security Statement
Within four to six weeks after you return this form, we will send you:
• a record of your earning history;
• an estimate of how much you have paid in Social Security taxes; and
• estimates of benefits you (and your family) may be eligible for now and in the future.
Please note: If you have received periodic Social Security Statements in the mail, this request may stop your
next scheduled mailing.
We hope you will find the Statement useful in planning your financial future. Remember, Social Security is more than
a program for retired people. Social Security is with you throughout life's journey. For example, it can help support
your family when you die and pay you benefits if you become severely disabled.
If you have questions about Social Security or this form, please call our toll-free number, 1-800-772-1213 (TTY
1-800-325-0778)
Please check this box if you want to get your Statement in Spanish instead of English.
Please print or type your answers. When you have completed the form, mail it to:
Social Security Administration
Wilkes Barre Direct Operations Center
P.O. Box 7004
Wilkes Barre, PA 18767-7004
1. Name shown on your Social Security card:
First Name:
Middle Initial:
Last Name only:
2. Your Social Security number as shown on your card:
-
-
3. Your date of birth
/
/
4. Other Social Security numbers you have used:
-
-
-
-
5. Your Sex:
Male
Female
Form SSA-7004 (11-2017)
Page 2 of 3
For items 6 and 8, show only earnings covered by Social Security. Do NOT include wages from state, local, or
federal government employment that are NOT covered by Social Security or that are covered ONLY by Medicare.
6. Show your actual earnings (wages and/or net self-employment income) for last year and your estimated earnings
for this year.
.
0
0
A. Last year's actual earnings:
$
(Dollars Only)
.
B. This year's estimated earnings:
$
(Dollars Only)
0
0
7. Show the age at which you plan to stop working:
(Show only one age)
8. Below, show the average yearly amount (not your total future lifetime earnings) that you think you will earn
between now and when you plan to stop working. Include performance or scheduled pay increases or bonuses, but
not cost-of-living increases.
If you expect to earn significantly more or less in the future due to promotions, job changes, part-time work or an
absence from the work force, enter the amount that most closely reflects your future average yearly earnings.
If you don't expect any significant changes, show the same amount you are earning now (the amount in 6B).
.
0
0
Future average yearly earnings:
$
(Dollars Only)
9. Do you want us to send the Statement:
• To you? Enter your name and mailing address.
• To someone else (your accountant, pension plan, etc.)? Enter your name with "c/o" and the name and address of
that person or organization.
"C/O" or Street Address (Include Apt. No., P.O. Box, Rural Route)
Street Address
Street Address (If Foreign Address, enter City, Province, Postal code)
U.S. City, State, ZIP code (If Foreign Address, enter Name of Country only)
NOTICE:
I am asking for information about my own Social Security record or the record of a person I am authorized to
represent. I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I authorize you to
use a contractor to send the Social Security Statement to the person and address in item 9.
Please sign your name (Do Not Print)
(Area Code) Daytime Telephone Number
Date
Form SSA-7004 (11-2017)
Page 3 of 3
Privacy Act Statement
Collection and Use of Personal Information
Sections 205 (a), 205 (c)(2)(A) and 1143 (a)(2) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent the issuance of a Social Security statement.
We will use the information to accurately identify your Social Security earnings record, extract the recorded earnings
history, and to produce the requested statement. We may also share your information for the following purposes,
called routine uses:
1. To Federal, State, or local agencies for the purpose of validating Social Security numbers used in
administering cash or non-cash income maintenance or health maintenance programs; and
2. To Federal, State, or local agencies for determining alien applicants' eligibility for benefit programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records
are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for
repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059, entitled
Earnings Recording and Self-Employment Income System, and 60-0224, entitled SSA-Initiated Personal Earnings
and Benefit Estimate Statement. Additional information and a full listing of all our SORNs are available on our website
at www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management
and Budget (OMB) control number. We estimate that it will take about 5 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.
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