Current SSA-1709

Form Approved
OMB No. 0960-0098

SOCIAL SECURITY ADMINISTRATION

REQUEST FOR WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT INFORMATION
PRIVACY ACT/PAPERWORK ACT NOTICE: Your response to
this request is voluntary; however, failure to provide all or part
of the requested information could prevent an accurate and
timely decision on this claim and could affect the claimant's
Social Security benefits. The Social Security Administration
uses the information you furnish to determine the effect of the
claimant's workers' compensation or public disability benefit
on his or her Social Security disability insurance benefits, as
provided in section 224 of the Social Security Act

(42 U.S.C. 424)The information on this form may be disclosed by the Social Security Administration to another person
or agency for the following purposes: (1) to assist the Social
Security Administration in establishing the right of a beneficiary
to Social Security benefits; (2) to facilitate statistical research
and audit activities necessary to assure the integrity and improvement of the Social Security programs; and (3) to comply
with laws requiring the exchange of information between the
Social Security Administration and another agency.

REQUESTING OFFICE

TO:

SIGNATURE OF SSA OFFICIAL
TITLE
DATE
COMPUTER MATCHING STATEMENT: 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 office. If
you want to learn more about this, contact any Social Security Office.

l. IDENTIFICATION OF WORKER (To be completed by the Social Security Administration)
NAME OF WORKER

2. SOCIAL SECURITY

3. ADDRESS OF WORKER

4. EMPLOYER'S NAME AND ADDRESS

5. CLAIM NUMBER(S)

6. DATE IF INJURY OR ONSET OF DISEASE
(if applicable)

I request and authorize release of information concerning my
claim for workers' compensation or other public disability
benefits to the Social Security Administration

Signature (If required by State or other entity)

INSTRUCTIONS FOR COMPLETION OF FORM

The Social Security Administration is required by law to reduce Social Security disability benefits when the worker
is also receiving worker's compensation, black lung benefits, or other public disability benefits. If your office has no
record of a claim by the worker named above, or if the worker filed a claim but was denied, please check the
appropriate block below, sign on the reverse, and return this form to the Social Security Administration.
No Record of Claim

Claim Denied - No Appeal

Claim Denied - Appeal Pending

If the claim by the named worker is pending, indicate when a decision is expected.
IF THE WORKER HAS EVER RECEIVED PERIODIC PAYMENTS OR A LUMP SUM AWARD, COMPLETE THE REVERSE SIDE OF
THIS FORM. IT IS IMPORTANT THAT ALL BENEFIT INFORMATION IS COMPLETED AS ACCURATELY AS POSSIBLE BECAUSE
THE WORKER'S SOCIAL SECURITY BENEFITS MAY BE REDUCED BASED ON THE INFORMATION PROVIDED.

RETURN TO:

SOCIAL SECURITY ADMINISTRATION

Form SSA-1709 (7-2003) EF (07-2003) Destroy Prior Editions

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 THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. To find the
nearest office, call 1-800-772-1213. Send only comments
on our time estimate above to:
SSA, 1338 Annex
Building, Baltimore, MD 21235-0001.
(Over)

II. INFORMATION REQUESTED (To be completed by addressee)
NOTE: A copy of the compensation decision, payment record, court order, award letter, etc. which clearly
shows the payment data requested below may be submitted in lieu of completing this form.

7. a. Periodic workers' compensation or public disability payments to worker
ATTORNEY FEES
DATE
ENTER TYPE OF PAYMENTS
AND OTHER
PAYMENT
DATE
WEEKLY
TEMPORARY
PERMANENT
EXPENSES INCLUDED
EFFECTIVE
ENDED
AMOUNT
IN WEEKLY AMOUNT PARTIAL TOTAL PARTIAL TOTAL

b. Most recent payment stopped because (Check appropriate block).
Lump-Sum Settlement PendingPermanent Rating Pending Decision Expected By
Decision Expected By
Award Under Appeal Other (Explain in "Remarks").
Decision Expected By
8. a. Lump sum payment to worker
DATE OF SETTLEMENT(S) GROSS AMOUNT(S) RATE(S) PER WEEK
b. The following expenses were deducted from the gross amount:

NUMBER OF WEEKS BEGINNING DATE

1. Present and past medical expenses

$

2. Future medical expenses

$

3. Attorney fees

$

4. Other related expenses (Explain in "Remarks".)

$

9. Are the benefits reduced ( or will be reduced) because

of the worker's receipt of Social Security Benefits?

10. If the payments are not workers' compensation, (for example, disability retirement)
and the worker was a State or local government employee, were Social Security
taxes ( that is, FICA taxes) paid on the worker's earnings? (If "No", go on to item 12.)

What were the total number
of years of service (FICA and
non-FICA)?

TOTAL
YEARS/MONTHS

TOTAL
YEARS/MONTH

No

Yes

No

How many years was the worker
engaged in employment "covered "
by Social Security?

11. If the disability payments are not workers' compensation, but are being made
under a Federal law or plan, was any of the worker's service covered under
Social Security (i.e., FICA taxes were paid), including military service after 1956?

What were the total number of
years of service (FICA and
non-FICA)?

Yes

YEARS/MONTHS

Yes

No

(If "No", go on to item 12.)

How many years was the worker engaged in
Federal employment covered by Social
Security, including military service after
1956, but not military service before 1957?
(OPM - Include deposit service.)

YEARS/MONTHS

12. Remarks

I declare under penalty of perjury 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. I understand that anyone who
knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to
do so, commits a crime and may be sent to prison, or may face other penalties, or both.
TELEPHONE NO. (include area code)
13. SIGNATURE OF PERSON COMPLETING THE FORM
TITLE
Form SSA-1709 (7-2003) EF (07-2003)

DATE