Time It Takes To Complete This Form

We estimate th at it will take you about 15 minutes to complete this form. Th is includes the time it will take to read the in structions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, or on any other aspect of this form, write to the Social Security Administration, ATTN Reports Clearance Officer, l-A-21 Operations Bldg., Baltimore, MD, 21235-0001, and to the Office of Management and Budget, Paperwork Reduction Project (0960-0511), Washington, D.C. 20503. Send only comments relating to our estimate or other aspects of this form to the offices listed above. All requests for Social Security cards and other claims related information should be sent to your local Social Security office whose address is listed in your telephone directot}* under the Department of Health and H uman Services.

Name and Address Claim Number

John Smith 000-00-0000

123 4th St.

Baltimore, MD 21241_

1. Within die last 2 years have you worked for someone or been self-employed?

If yes, please complete the informat ion Ix-low.

Work Began Work Emied Monthly

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