Fill and Sign the Supporting Statement for Form Ssa 7008 Reginfogov

Form Approved SOCIAL SECURITY ADMINISTRATION OMB NO. 0960-0029 REQUEST FOR CORRECTION OF EARNINGS RECORD Paperwork/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 w ill 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. 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. 1. Print your name (First Name, Middle Initial, Last Name) 2. Enter your date of birth (Month, Day, Year) 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.") (2) / / (Without permission to use your name, SSA cannot make a thorough investigation.) (3) / / 5. (b) Enter any other Social Security number(s) used by you or your employer to report your wages or self-employment. none, check, "None." (1) None 6. SSA MAY DISCLOSE MY NAME TO MY EMPLOYERS: 5. (a) Enter your Social Security number YES NO If IF NECESSARY, 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. W2 or W-2C Other (Specify) W2 or W-2C Other (Specify) W2 or W-2C Other (Specify) (c) 1. 2. (b) 1. 2. 1 - Year(s) (or months) of employment 2 - Type of employment (e.g., agricultural) Employer's business name, address, and phone number (include number, city, state, and zip code) My correct Social Security(FICA) wages were: My evidence of my correct earnings (enclosed) (a) 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 self- employment My correct self-employment earnings were: FORM SSA-7008 (5-1988) (12-2001) (over) $ $ EF YES NO YES NO YES NO 9. Regarding your earnings from self-employment: a. Did you file an income tax return reporting your self- employment income? b. Do you have a copy of your income tax return and evidence of filing such as a canceled check? c. Have you asked the Internal Revenue Service to furnish you copies from their records? (If "YES," go on to (If "NO," explain Item 9b.) why in Item 10). (If "YES," please (If "NO," go on to enclose copies.) Item 9c.) (But none available) (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). We may also use the information you give us when we match records by computer. Matching programs compare our records with thos e of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qual ifies 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 Secu rity Offices. If you want to learn more about this, contact any Social Security Office. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. We estimate that it will take you about 10 minutes to complete t his form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. 11.  I affirm that all the information I have given in this document is true to the best of my knowledge, I understand that if I knowingly and willfully make a false statement, or request or receie a Social Security record under false pretenses, I may be guilty of a Federal crime and could be fined as much as $5,000 and/or imprisoned for up to 5 years. Signature of person making statement (First Name, Middle Initial, Last Name) Mailing Address (Number & Street, Apt. No., P.O. Box, Rural Route) City State Zip Code Telephone Number (Include Area Code): 1. Work ( ) 2. Home ( ) Date 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 (5-1988) EF (12-2001)