Form SSA-512 Request to Resolve Questionable Quarters of Coverage

Form Approved
OMB No: 0960-0575

Social Security Administration

Date of Request:________________

REQUEST TO RESOLVE QUESTIONABLE QUARTERS OF COVERAGE (QC)

Complete the information below when the QC array contains either a (#) pound sign or code "Z" prior to
1798. Mail the form and a copy of the system's printout to the Social Security Administration, PO Box 17750,
Baltimore, MD. 21235-0001.
Print Name: (Last, First, Middle)

SSN

Date of Birth (MM-DD-YY)
-

-

Request Years
19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

19_______,

OR
19_______ thru 19_______

19_______ thru 19_______

19_______ thru 19_______

Address (Number, City, State, Zip Code)

Contact Person's Name

Form SSA-512 (12-2006)

Contact Person's Telephone Number

(OVER)

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 2 minutes to read the instructions, gather the facts, and answer the questions. The office is
listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.

SSA-512 (12-2006)