SSA-L9784 Retirement, Survivors and Disability Insurance: Earnings

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

THOMAS L HEMINGWAY
8704 LYNN SUSAN COURT
SPRINGFIELD VA 2216Z2756

Date: August 8,2005

Claim Number: 545-56-8945A

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I am writing to ask your help in making sure that we are paying you the correct
amount of Social Security bendts. We need you to give us current information
about your work.
e months before a person becojnes full rethemeat age ( m n t l y
fi%?%i&onths
for people born in 194g and gradually increasing to 67 for
persons bom4n 1960 or later) can reduce the amount of Social Security bench.
Because we want to make sure that we pay you accurately, we want you to give
us an earnings estimate for this year.

The enclosed form has some questions about your work for this year. After you
complete it, please mail it in the enclosed envelope. W e need to hear from you
as soon as possible.
Thank you for taking the time to assist us. W e wouldlike to give you the best
possible senice and hope $hat you h d this form a convenient way to M r m us
about your work.

If you have any questions, you c a n call us toll free at 1-800-772-1213,7:00 a.m. to

7:00 p.m. Monday through Friday. We c a n answer most questions over the phone.
Our busiest times are the &st week of the month and Mondays. So, we may be able t o
handle your call more quickly if you c a n call us at other e e s . If you prefer ta visit or
call one of our &ces, use the 800 number and we can give you the &ce address and
telephone number. Please have this letter with you if you call or visit an o&e. It will
help us auswer your questions,
Sincerely,

omm missioner

Social Security Administration

Enclosures:
Earnings Estimate Form SSA-L9784-SM
Envelope

Form SSA-L9784-SM (7 -2005)

Page 2

In 20@, the full rehement age for p
you were born on the fist day of the
retirement age in the prior month, For e
you as if you reached full retirement age in
~ p ~ ! - a ~ a1.194,
e
you o d y have t o report wage
Question 1 shows the month you will reach

~fyou were born -2,
retirement age in 200

I
k
0
t
b
gh Jmuary 1 . 1 ~ 4 m a f ~~l l h
age 66 m dkk onths). This mema you only have to report
wages for the months before you reach full retirement age in 2w. Question 1
shows the month you will reach full r e ~ e m etnage.
6

If you are paid wages, base your estimate'on what you expect to earnbefore taxes or
other deductions up to the month you become full.retirement age. Be sure to
include bonuses, vacation pay, sick pay, tips of $20 or more a month, and any
contribution that you make h m your salary to a tax deferred savinga plan.

+ Drop from your estimate any money you will get from your employer prior t o the month
you are full retirement age for work you did last year or before. Also, do not include:
S a i d Security, radroacl or civil
s e ~ c retirement,
e
veterans,
black lung or public assistance

gifts or inheritances;

pensions and other retirement
payments which are not
reported on your W-2 form;

rental income;

gain (or loss) &om the sale of capital
wts;

bend&;

unemployment or worker's
compensation;

a investment income;

interest h m savings accounts;
M e insurance annuities and

dividends;

+

Ifyou are self-employed, base your estimate on what you think your net
earningswillbe- 'ustlikeon urtaxreturn. IfyoubecameentitledtoSocial
Security benefits efore 2 0 9 8 4 1) do not include ' your estimate any Federal
agricultural program payments yau expect in 2 0 9 6 k d (2) do not include
self-employment income received in 2 0 q m carry-overcrops for work you
did before you became entitled to Social ecurity benefits.

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If you are self-employed, we will reduce-yourestimatedself-employment earnings
to a&ust for the period you are full retirement age and over.

Now, you are ready to answer the following questions about your earnings. And again,
born vou,

Form SSA-L9781-Shl ( 7 - 2 ~ # )
k

I'onn Approved

OMB NO.0960-0369

Page I

I

1

How much do you

year in wagee before
retirement age in
Show your answer in the space below.

2

How much do you think you will earn in
selEemployment in 200119

G

If you are self-employed, we will reduce your estimated self-emp1.oyment
earnings to adjust for the period you are full retirement age and over.

Show your net self-emploment earnings for the whole year in the space
below.

Please go on to the next question.

Page 2

To help us make sure that we understand your answers, we would like to
know if you have retired, or if you plan b retire this year.

3

Have you retired, or do you plan to retire in 200jh
b

If you retrred, or plan ta retire &om your regular (full-time) employment in
2008 answer ''YES'' to this question even i€you work or plan to work parktime.6
Show an T on the line next ta your answer.

NO, I have not retired and I am not going to retire this year.
YES, I have retired, or plan to retire this year.
If you answered "yes", please show your retirement date in the space
below.

(MONTH, DAY, YEAR)
Remember, you need to return this form as soon as possible.
-.
Y

,

*

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 ddare under penalty of perjury that I have exsmined d the information
on this form, and on any accompanying statements or forms, and it is tmre
and correct to the best of my howledge.

Your Signature

Date

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

Area Code

Telephone Number
Form SSA-LR7H4-SM (7-200i)
&9

Page 3

PRIVACY ACT STATEMENT

The Social Security Administration (SSA)is authorized to collect information on
this form under section 206 (a) and section 203 (h) (3), (4) of the Social Security Act.
Giving us this dormation is voluntary. You do not have to do it; but we may not be
paying you the right a m o u n t d e s s 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 dormation 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 h d or prove
that a person qu&es for benefits paid by the Federal Government. The law allows
us to do this even if yov do not agree to it.

Explma tions about these and other reasons why information you prwide 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 o k .

PAPERWORK REDUCTION ACT STATEMENT
Paperwork Reduction Act Sttltement - This information collection meets the
requirements of 44 U.S.C. 5 3507, as amended by Section 2 of the B
m
on Act of 1996, You do not need to answer these questions unless we display
a valid a c e of Management and Budget control number. We e s e a t e that it will

&mrnneenb
on ourtime estimate above to: SSA,
Bait irnore, MD 21235-0001,

Form SSA-L0784-SM(7-200b

b