Front:
MISS
NAME MARS
MR.
STREET & NUMBER
CITY & STATE
REQUEST FOR
STATEMENT
OF EARNINGS
SOCIAL
SECURITY
NUMBER
SIGN YOUR NAME AS
YOU USUALLY WRITE IT
DATE OF
BIRTH
418
MONTH
SEPT
Please send a statement of the amount of earnings recorded in my social security account to:
VERTHOR NOLAN
BARNETT
7109 QUAIL ROAD
05 6750
DAY
YEAR
18 1916
ZIP CODE
FAIR OAKS CALIE
Vertuor N. Barnett
Specifications for this form were secured
from the Social Security Administration
95628
Print
Name
In Ink
Or Use
Type
writer
Sign your own name only. Under the law, information in your social security record is
confidential and anyone who signs someone else's name can be prosecuted.
If your name has been changed from that shown on your social security account number
card, please copy your name below exactly as it appears on that card.
Back:
YOUR SOCIAL SECURITY
ACCOUNT
If you want a state
your Social Security A
fill out the other side
card.
Be sure to give y
count number exactly!
shown on your accoun
ber card, in order toaster Seals 1967
sure your account is p
identified. If you hav
than one account n
give all of them.
It is not necessary for
pay anyone to aid you in
ing this information.
no charge for this servicEaster Seals 1967
Be sure to place a stamp on
this card before mailing it to
us.
This card is furnished through the courtesy
of the
UNITED SERVICES LIFE INSURANCE CO.
Washington, D. C.
FAIR
OAKS
APR 8
.. PM
1967
95628
CA
BDPA-AB 1987AF 12
P.O. BOX 57
SOCIAL SECURITY ADMINISTRATION
BALTIMORE, MD. 21203
REA
