Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form Page 7

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A complete list of routine uses for this information is available in our System of Records Notices entitled Earnings
Recording and Self-Employment Income System, 60-0059. The notice, additional information regarding this form,
and information regarding our system and programs, are available on-line at 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 30 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
999999999-99-MMDDYY
SSA-95-SM (04-11)

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