Free Request For Correction of Earnings Record - Federal

SOCIAL SECURITY ADMINISTRATION

Form Approved OMB NO. 0960-0029

REQUEST FOR CORRECTION OF EARNINGS RECORD
Privacy Act Notice: The information requested on this form is authorized by section 205(c)(4) and (5) of the Social Security Act. This information is collected to resolve any discrepancy on your earnings record. The information you provide will be used to correct your earnings record where any discrepancy exists. Your response to this request is voluntary; however, failure to provide all or part of the requested information may affect your future eligibility for benefits and the amounts of benefits to which you may become entitled. Information furnished on this form may be disclosed by the Social Security Administration to another person or governmental agency only with respect to Social Security programs to comply with Federal laws requiring the exchange of information between the Social Security Administration and another agency. (Privacy Act continued on the back.)

I have examined your statement (or record) of my Social Security earnings and it is not correct. I am providing the following information and accompanying evidence so that you can correct my record. 2. Enter your date of birth (Month, Day, Year) 1. Print your name (First Name, Middle Initial, Last Name) 3. Print your name as shown on your Social Security number card 4. Print any other name used in your work. (If you have used no other name enter "None.") 5. (a) Enter your Social Security number 5. (b) Enter any other Social Security number(s) used by you or your employer to report your wages or self-employment. If none, check "None."

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(1) (2) (3)

None

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YES NO

6. IF NECESSARY, SSA MAY DISCLOSE MY NAME TO MY EMPLOYERS: (Without permission to use your name, SSA cannot make a thorough investigation.)

If you disagree with wages reported to your earnings record, complete Item 7. If you disagree with self-employment income recorded on your earnings record, go to Item 8. 7. Print below in date order your employment only for year(s) (or months) you believe our records are not correct. If you need more space, attach a separate sheet. Please make only one entry per calendar period employed. Show quarterly wage periods and amounts for years prior to 1978; annual amounts, 1978 on. 1 - Year(s) (or months) of Employer's business name, address, My correct My evidence of my correct employment Social Security earnings (enclosed) and phone number (include number, (FICA) wages city, state, and ZIP code) 2 - Type of employment were: (e.g., agricultural) (a) 1. 2. (b) 1. 2. (c) 1. 2. If you do not have evidence of these earnings, you must explain why you are unable to submit such evidence in the remarks section of Item 10. If you do not have self-employment income that is incorrect go on to item 10 for any remarks, and then complete Item 11. 8. Print below in date order your self-employment earnings only for years you believe our records are not correct. Please make only one entry per year. Trade or business name and business address Year(s) of selfemployment My correct self-employment earnings were:
W2 or W-2C Other (specify) W2 or W-2C Other (specify) W2 or W-2C Other (specify)

(a) (b)
Form SSA-7008 (2-2005) ef (2-2005)

$ $
(over)

9. Regarding your earnings from self-employment: a. Did you file an income tax return reporting your selfemployment income?

YES
(If "YES," go on to Item 9b.)

NO
(If "NO," explain why in Item 10).

b. Do you have a copy of your income tax return and evidence of filing such as a canceled check?

YES
(If "YES," please enclose copies.)

NO
(If "NO," go on to Item 9c.)

c. Have you asked the Internal Revenue Service to furnish you copies from their records?

YES
(But none available)

NO
(If "NO," please do so if your return was filed less than 6 years ago.)

d. If you are unable to submit a copy of your self-employment tax return, please explain in the remarks section (Item 10). 10. Remarks -- You may use this space for any explanations. (If you need more space, please attach a separate sheet).

Privacy Act (Continued from the front): COMPUTER MATCHING STATEMENT: We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security Office. 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 control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

11. 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 understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature of person making statement (First Name, Middle Initial, Last Name) Mailing Address (Number & Street, Apt. No., P.O. Box, Rural Route) City Date State ZIP Code Telephone Number (Include Area Code): 1. Work

2. Home

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When you have filled out this form, mail it in an envelope addressed to: Social Security Administration 300 N. Greene Street Baltimore, Maryland 21201
Form SSA-7008 (2-2005) ef (2-2005)