Ssa 7050 F4 PDF Details

The Ssa 7050 F4 form is an important document for those seeking Social Security Disability benefits. This page will provide a brief overview of the form and what it is used for. Additionally, we will provide some tips on how to best complete the form so that your application has the best chance of being approved. If you are considering applying for Social Security Disability benefits, you will need to complete the Ssa 7050 F4 form. This form is used to provide information about your medical history and current condition. It is important to be as thorough as possible when completing this form, so that your application has the best chance of being approved.

We have gathered some general facts about the ssa 7050 f4. This page provides information regarding the form's size, finalization duration, and the blanks you may be expected to fill.

Form NameSsa 7050 F4
Form Length4 pages
Fillable fields1
Avg. time to fill out1 min 12 sec
Other namessocial security earnings information, social security form 7050, security social information, social security administration form 7050

Form Preview Example

Form SSA-7050-F4 (02-2021)


Discontinue Prior Editions

Page 1 of 4

Social Security Administration

OMB No. 0960-0525


*Use This Form If You Need

1.Certified/Non-Certified Detailed Earnings Information Includes periods of employment or self-employment and the names and addresses of employers.

2.Certified Yearly Totals of Earnings

Includes total earnings for each year but does not include the names and addresses of employers.



Yearly earnings totals are free to the public

if you do not require certification.

To obtain FREE yearly totals of earnings, visit our website at

Privacy Act Statement

Collection and Use of Personal Information

Section 205 of the Social Security Act, as amended, allows us to collect this information. In addition, the Budget and Accounting Act of 1950 and Debt Collection Act of 1982 authorize us to collect credit card information, if you choose to pay for the earnings information you have requested with a credit card. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from processing your request.

We will use the information to identify your records, process your request, and send the earnings information you request. We may also share the information for the following purposes, called routine uses:

1.To the Internal Revenue Service (IRS) for auditing SSA's compliance with the safeguard provisions of the Internal Revenue Code of 1986, as amended.

2.To contractors and other Federal agencies, as necessary, for the purpose of, assisting the Social Security Administration (SSA) in the efficient administration of its programs.

3.To banks enrolled in the Treasury credit card network to collect a payment or debt when the individual has given his/her credit card number for this purpose.

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, 60-0090, entitled Master Beneficiary Record, 60-0224, entitled SSA-Initiated Personal Earnings and Benefit Estimate Statement, and 60-0231, entitled Financial Transactions of SSA Accounting and Finance Offices. Additional information and a full listing of all our SORNs are available on our website at

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 11 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.

Form SSA-7050-F4 (02-2021)

Page 2 of 4


1.Provide your name as it appears on your most recent Social Security card or the name of the individual whose earnings you are requesting.

First Name:

Last Name:

Social Security Number (SSN)

Date of Birth:

Middle Initial:

One SSN per request

Date of Death:

Other Name(s) Used

Maiden Name

2.What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return this request.)

Itemized Statement of Earnings $92.00

(Includes the names and addresses of employers)

If you check this box, tell us why you need this information below.

Year(s) Requested:






Year(s) Requested:




















Check this box if you want the earnings information CERTIFIED for an additional $30.00 fee.

Certified Yearly Totals of Earnings $30.00

(Does not include the names and addresses of employers)Yearly earnings totals are FREE to the public if you do not require certification. To obtain FREE yearly totals of earnings, visit our website at

Year(s) Requested:

Year(s) Requested:



3.If you would like this information sent to someone else, please fill in the information below. I authorize the Social Security Administration to release the earnings information to:









ZIP Code

4.I am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual).

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.

Signature AND Printed Name of Individual or Legal Guardian

SSA must receive this form within 120 days

from the date signed






Relationship (if applicable, you must attach proof)


Daytime Phone:








ZIP Code




Witnesses must sign this form ONLY if the above signature is by marked (X). If signed

by mark (X), two witnesses to the

signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the

mark (X) on the signature line above.



1. Signature of Witness

2. Signature of Witness



Address (Number and Street, City, State and ZIP Code)

Address (Number and Street, City, State and ZIP Code)




Form SSA-7050-F4 (02-2021)

Page 3 of 4



You may use this form to request earnings information for one ONE Social Security Number (SSN)

How do I get my earnings statement?

You must complete the attached form. Tell us the specific years of earnings you want, type of earnings record, and provide your mailing address. The itemized statement of earnings will be mailed to ONE address, therefore, if you want the statement sent to someone other than yourself, provide their address in section 3. Mail the completed form to SSA within 120 days of signature. If you sign with an "X", your mark must be witnessed by two impartial persons who must provide their name and address in the spaces provided. Select ONE type of earnings statement and include the appropriate fee.

1. Certified/Non-Certified Itemized Statement of Earnings

This statement includes years of self-employment or employment and the names and addresses of employers.

2. Certified Yearly Totals of Earnings

This statement includes the total earnings for each year requested but does not include the names and addresses of employers.

If you require one of each type of earnings statement, you must complete two separate forms. Mail each form to SSA with one form of payment attached to each request.

How do I get someone else's earnings


You may get someone else's earnings information if you meet one of the following criteria, attach the necessary documents to show your entitlement to the earnings information and include the appropriate fee.

1. Someone Else's Earnings

The natural or adoptive parent or legal guardian of a minor child, or the legal guardian of a legally declared incompetent individual, may obtain earnings information if acting in the best interest of the minor child or incompetent individual. You must include proof of your relationship to the individual with your request. The proof may include a birth certificate, court order, adoption decree, or other legally binding document.

2. A Deceased Person's Earnings

You can request earnings information from the record of a deceased person if you are:

• The legal representative of the estate;

• A survivor (that is, the spouse, parent, child, divorced spouse of divorced parent); or

• An individual with a material interest (e.g., financial) who is an heir at law, next of kin, beneficiary under the will or donee of property of the decedent.

You must include proof of death and proof of your relationship to the deceased with your request.

Is There A Fee For Earnings Information?

Yes. We charge a $92.00 fee for providing information for purposes unrelated to the administration of our programs.

1.Certified or Non-Certified Itemized Statement of Earnings

In most instances, individuals request Itemized Statements of Earnings for purposes unrelated to our programs such as a private pension plan or personal injury suit. Bulk submitters may email for an alternate method of obtaining itemized earnings information.

We will certify the itemized earnings information for an additional $30.00 fee. Certification is usually not necessary unless you are specifically requested to obtain a certified earnings record.

Sometimes, there is no charge for itemized earnings information. If you have reason to believe your earnings are not correct (for example, you have previously received earnings information from us and it does not agree with your records), we will supply you with more detail for the year(s) in question. Be sure to show the year(s) involved on the request form and explain why you need the information. If you do not tell us why you need the information, we will charge a fee.

2. Certified Yearly Totals of Earnings

We charge $30.00 to certify yearly totals of earnings. However, if you do not want or need certification, you may obtain yearly totals FREE of charge at Certification is usually not necessary unless you are advised specifically to obtain a certified earnings record.

Method of Payment

This Fee Is Not Refundable. DO NOT SEND CASH.

You may pay by credit card, check or money order.

• Credit Card Instructions

Complete the credit card section on page 4 and return it with your request form.

• Check or Money Order Instructions

Enclose one check or money order per request form payable to the Social Security Administration and write the Social Security number in the memo.

How long will it take SSA to process my request?

Please allow SSA 120 days to process this request. After 120 days, you may contact 1-800-772-1213 to leave an inquiry regarding your request.

Form SSA-7050-F4 (02-2021)

Page 4 of 4


Where do I send my complete request?

Mail the completed form, supporting documentation,

If using private contractor such as FedEx mail form,

and applicable fee to:

supporting documentation, and application fee to:

Social Security Administration

Social Security Administration

P.O. Box 33011

P.O. Box 33011

Baltimore, Maryland 21290-33011

Baltimore, Maryland 21290-33011



How much do I have to pay for an Itemized Statement of Earnings?

Non-Certified Itemized Statement of Earnings

Certified Itemized Statement of Earnings



How much do I have to pay for Certified Yearly Totals of Earnings?

Certified yearly totals of earnings cost $30.00. You may obtain non-certified yearly totals FREE of charge at Certification is usually not necessary unless you are specifically asked to obtain a certified earnings record.


As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will

apply. You also pay by check or money order. Make check payable to Social Security Administration.















American Express



























































Credit Card Holder's Name






























(Enter the name from the credit card)




































First Name, Middle Initial, Last Name


Credit Card Holder's Address








































Number & Street









































City, State, & ZIP Code


Daytime Telephone Number
































































Area Code






















Credit Card Number























































































































Credit Card Expiration Date


























































Amount Charged






























See above to select the correct fee for your request.





























Applicable fees are $30.00, $92.00, or $122.00.




























SSA will return forms without the appropriate fee.




























































Credit Card Holder's Signature













































































































































































Remittance Control #

















































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