On Form SSA-7004-SM-OP1, we ask requesters to give us:

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  their name and SSN as shown on their Social Security card,

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  their date of birth and sex, and

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  any other SSNs they may have used.

We use this information to verify that the SSN record requested belongs to the person requesting the Statement.

We ask requesters to tell us how much they earned last year because these earnings may not yet be posted to their record. We also ask them to tell us how much they expect to earn this year and the average earnings they expect to have in future years before they stop working. Requesters are cautioned on the form to include only earnings that are covered by Social Security; noncovered earnings will distort the benefit estimate calculations.

We use the earnings information the requesters provide to calculate credits for insured status if the SSN holder is not already insured based on the posted earnings record. We also use it to calculate benefit estimates. If the requester does not complete these items on the form, we will use $0 for the earnings amounts.

We will use the age the requester plans to stop working to calculate credits and compute benefit estimates.

Generally, we mail an on-request Statement directly to the SSN holder who asked for it. Some SSN holders, however, want their Statements to go to a third party such as their accountant, financial advisor or pension plan agent. We will accommodate these requests by sending the Statement in care of the third-party address. Instructions on the Form SSA-7004-SM-OP1 tell the requester how to enter the address.

SSA disclosure policies and those of the Internal Revenue Service (which govern release of the earnings information on the Statement) require SSN holders to sign and date their request for a Social Security Statement. On Form SSA-7004-SM-OP1, the signature line follows a Statement in which the requester acknowledges that deliberately requesting information under false pretenses may subject him or her to fines and/or imprisonment. The date the request form (or other correspondence) is signed must not be more than 60 days before the date SSA receives it.

We provide the Form SSA-7004-SM-OP1 in both English and Spanish. Requesters who send in an English form will receive an English Social Security Statement in response. A Spanish request form will generally result in a Spanish statement. However, each version of the SSA-7004-SM-OP1 also contains a check block that the requester can use to ask for the statement in the other language.

To view the form, go to OS 15010.825.

To view the form, go to OS 15010.830.

Items 1 through 5 on the Form SSA-7004-SM-OP1 ask for the requester’s identifying information (name, SSN(s), date of birth and sex. Items 6 and 8 request earnings information for last year, this year and future years. Item 7 asks when the requester plans to stop working. Item 9 asks for the requester’s mailing address or the “care-of” address of a third party if the requester wants the Statement to be sent to someone else. At the bottom of the last panel of the form is a penalty notice and signature line. We also ask for the requesters’ daytime telephone numbers in case we need to contact them about missing or unclear information.

The Form SSA-7004-SM-OP1 comes with a mailing envelope addressed to WBDOC at:

(The OP2 business reply version of the envelope bears the ZIP code 18767-9976.)

There are several versions of the paper Form SSA-7004-SM-OP:

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  SSA-7004-SM-OP1 is the basic paper version that we provide to both individual requesters and organizations or agencies that ask for supplies of the form. SSA-7004-SM-SP-OP1 is the same form printed in Spanish.

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  SSA-7004-SM-OP2 is the business reply version of the form. It is sent for completion to requesters whose original request forms cannot be processed because they are damaged, illegible or incomplete. SSA-7004-SM-SP-OP2 is the same form in Spanish. (The form inside the envelope is version OP1; the envelope is designated OP2 for differentiation in requesting supplies.)

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  SSA-7004-SM (SPEC), which is available in both English and Spanish, is a sample form that we give to large employers, unions, organizations, etc. that want to print their own supplies of the form. It shows the current format and has an attachment with instructions about size limits, weight of paper and other conditions that the requesting organization must follow to make their printings acceptable.

CAUTION: Any versions of the Form SSA-7004-SM-OP with a print date earlier than 06/88 are not acceptable for processing.