SSA-L9790 Retirement, Survivors and Disability Insurance: Earnings

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

Date: August 8, 2008
Claim Number: ssn - bic
address data

I am writing to ask your help in making sure that we are paying you the correct
amount of Social Security benefits. We need you to give us current information
about your work for (e)Y¥YY.
The enclosed form has some questions about your work for (e)Y¥YY. After you
complete it, please mail it in the enclosed envelope. If we do not receive this information
within 30 days, we will assume that you worked all months in (e)Y¥YY.
Thank you for taking the time to assist us. We would like to give you the best possible
service and hope that you find this form a convenient way to inform us about your work.

If you have any questions, you can call us toll free at 1-800-772-1213, 7:00 a.m. to
7:00 p.m. Monday through Friday. We can answer most questions over the phone.
Our busiest times are the first week of the month and Mondays. So, we may be
able to handle your call more quickly if you can call us at other times. If you prefer
to visit or call one of our offices, use the 800 number and we can give you the office
address and telephone number. Please have this letter with you if you call or visit
an office. It will help us answer your questions.

Sincerely,

Commissioner
Social Security Administration

Enclosures:
Nonwork Months Form SSA-L9790-SM
Envelope

Form SSA-L9790-SM (7-2008)

Form Approved

OMB No. 0960-0369
Page 1

(a) BENEFICIARY NAME

But if we know how
much you earned before
taxes in each month in
(f)YYYY, we may be
able to pay you more.

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b) XXX-XX-XXXX(c)
(d) MM/YY
(e) MMIYY

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Your Monthly Earnings
Usually, if you make more than the earnings limit, which in (f)YYYY is $(g)AEA,
we have to hold back some of your Social Security. But if we know how much
you earned in each month in (f)YYYY, we may be able to pay you more.

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The same is true of self-employed people. The difference is that we need to know
how many hours you worked in each month, instead of the amount of money you
earned.
For the following months in (f)YYYY, you previously told us that you would not
earn over $(h)MEA and would not work over 45 hours in self-employment.
(i) Nonwork Months

you worked for wages, put an ''X'' in the box under
1. Ifeach
month when you earned $(h)MEA or less. Be sure
to do it for the whole year.
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were self-employed, how many hours did you work
2. Ifin you
each month in (f)YYIT? Be sure to put something

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!!!!!!!!!!!!!!

down for each month.
Show your hours in the boxes below.

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Please answer question 3 on the next page.

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Form SSA-L9790-SM (7-2008)

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Page 2

To help us make sure that we understand your answers, we would like to
know if you stopped working in (f) ¥YYY.

3. Did you stop working in (f)YYYY?
Show an "X" in the box next to your answer.

DNO

D YES,

I stopped working in (f)YYYY.
the date you last worked
If you answered "yes", please show 3 ... ....-.1l·em8Bl date m the space
below.

DO / DO / ITIIJ
Month I Day

I

Year

Remember, you need to return this form within 30 days.
Please sign this form in the space below, and send it back to us in the
enclosed envelope. And again thank you for your help.
I declare under penalty 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.

Your Signature

Date

Also, please give us a telephone number where we can reach you during the day.

/
Area Code

Telephone Number

For SSA Use ONLY
Ext.

WE 1 WE 2 WB 3

DODD

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Form SSA-L9790-SM (7-2008)

Page 3

PRIVACY ACT STATEMENT
The Social Security Administration (SSA) is authorized to collect information on
this form under section 205 (a) and section 203 (h) (3), (4) of the Social Security Act.
Giving us this information is voluntary. You do not have to do it, but we may not be
paying you the right amount unless you give us this information.
We use the information you give us to insure that we are paying you correctly.
However, we may share this information with another person or government agency
to manage the Social Security program or other programs that must be coordinated
with the SSA.
We may also use the information you give us in computer matching programs.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies 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 Security offices. If you want to learn more
about this, contact any Social Security office.
PAPERWORK REDUCTION ACT STATEMENT
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 10 minutes to read the instructions, gather the facts, and answer the
questions. To find the nearest office, call 1-800-772-1213. Send 2ll.ly comments
on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-0001.

Form SSA-L9790-SM (7-2008)