Appendix F: Sample SSA-5058 PC Form

Department of Health and Human Services
Social Security Administration

 

We have received your request and it is now being processed.

 

We try to respond promptly to all requests. However, some requests require rather extensive record searching and processing. A complete reply will be sent as soon as possible.

 

Form SSA-5058 PC (9-77)

Reissued March 1, 2012, replacing April 19, 2001