Your response is voluntary; however, failure to provide all or part of the requested information could prevent an accurate and timely return of the requested information. The Social Security Administration will provide this information based on Public Law 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The information on this form will not be disclosed to any other agency.
We estimate that it will take you about two minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts, and fill out the form. If you have comments or suggestions about this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235-0001. Send only comments relating to our “time it takes” estimate to the office listed above. All requests for Social Security Cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.
Reissued March 1, 2012, replacing April 19, 2001