Form HA-4633 Claimant's Work Background

SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals

Form Approved
OMS No 0960-0300

CLAIMANT'S WORK BACKGROUND
A. To be completed by Hearing Office
(Claimant and Social Security Number)

(Wage Earner and Social Security number)
(Leave blank if same as claimant)

The last time we
brought your case
up-to-date was:

B. To be completed by the claimant

PLEASE PRINT

Start with your most recent job, and list that and any work performed within the past 15 years.
DATES OF
EMPLOYMENT
(APPROXIMATELY)

NAME OF EMPLOYER AND
LOCATION OF EMPLOYMENT

DUTIES PERFORMED

FROM
TO

FROM
TO

FROM
TO

FROM
TO

Form HA-4633 13-1994) EF 110-2003)
Issue Old Stock

PLEASE READ PRIVACY ACT
STATEMENT ON REVERSE

If more space IS needed,

use additional sheets.

PRIVACY ACT AND PAPERWORK ACT NOTICE

See Revised
Privacy Act
Statement below

The Social Security Act (sections 205(a), 702, 1631 (e)(I)(A) and (B), and 1869(b)(1) and (C), as
appropriate) authorizes the collection of information on this form. We will use the information on your work
background to help us decide if we need to obtain more information. You do not have to give it, but if you do
not you may not receive benefits under the Social Security Act. We may give out the information on this form
without your written consent, if we need to get more information to decide if you are eligible for benefits or
if a Federal law requires us to do so. Specifically, we may provide information to another Federal, State, or
local government agency which is deciding your eligibility for a government benefit or program; to the
President or Congressman inquiring on your behalf; to an independent party who needs statistical information
for a research paper or audit report on a Social Security program; or to the Department of Justice to represent
the Federal Government in a court suit related to a program administered by the Social Security
Administration.
We may also use the information you give us when we match records by computer. 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 - 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 15 minutes to read the instructions, gather the facts, and answer the questions. SEND TIlE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under
U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building,

Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the
completedform.

Form HA·4633 (3-1994)

EF (10-2003)

G.o-

u.s. GOVERNMENT PRINTING OFFICE: 2006-320-638/00650

The following Privacy Act Statement will be inserted into the form at its next scheduled
reprinting:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631 (e)(1)(A) and (B) and 1869(b)(1)(C) of the Social Security Act, as
appropriate, authorize us to collect the information on this form. The information you provide
will help us to determine your potential eligibility for benefit payments and/or help us to decide if
additional information is needed. Your response is voluntary. However, failure to provide the
requested infonnation may prevent an accurate and timely decision on any claim filed, or could
result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining
entitlement to benefit payments. In accordance with 5 U.S.C. § 552a(b) of the Privacy Act,
however, we may disclose the information provided on this form in accordance with approved
routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance

programs at the Federal, state and local level;

3. To comply with Federal laws requiring the disclosure of the information from our
records; and
4. To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of SSA programs.
We may also use the infonnation you provide when we match records by computer. Computer
matching programs compare our records with those of other Federal, state or local government
agencies. Information from these matching programs can be used to establish or verify a person's
eligibility for federally funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs. The law allows us to do this even if you do not agree
to it.
Additional information regarding this form, routine uses of infonnation, and other Social Security
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.