Current HA-4633

Form Approved
OMB No.0960-0300

SOCIAL SECURITY ADMINISTRATION
Office of Disability Adjudication and Review

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

(Wage Earner and Social Security Number) The last time we brought your case
(Leave blank if same as claimant)
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.
DATE OF EMPLOYMENT
NAME OF EMPLOYER AND
DUTIES PERFORMED
(APPROXIMATELY)
LOCATION OF EMPLOYMENT
FROM
TO

FROM
TO

FROM
TO

FROM
TO

Form HA-4633 (3-1994) ef (6-2009)
Issue Old Stock

If more space is needed,
use additional sheets.

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 information 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 information 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 information, and other Social Security
programs are available from our Internet website at www.socialsecurity.gov or at your local 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 OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office 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, 6401Security Blvd, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
Form HA-4633 (3-1994) ef (6-2009)