Front:
Form OAR-7004 (6-55)
Department of
HEALTH, EDUCATION, AND WELFARE
WAGE STATEMENT REQUEST
ACCOUNT NUMBER 42/-09-2489
SOCIAL SECURITY ADMINISTRATION,
Bureau of Old-Age and Survivors Insurance,
Baltimore 2, Md.
DATE OF BIRTH
√ 17 1901
Counted in Q/C-
(Month) (Day)
(Year)
Please send the a statement of amounts recorded in my Old-Age and Survivors
Insurance Account. PLEASE ADVISE 9tY'S OF COVERAGE."
Name { Mrs. MARY HELEN LOPER.
Print or
Туре
Name
Use Ink
Street and number 425, BARRANCAS AVE
City, P. O. zone, and State...WARRINGTON FLA
Mary
Helen Loper
Sign your name as usually written
(Do not print)
WARNING! Sign your own name only. Whoever falsely represents that he is
the person whose name and account number appear above is subject to $1,000
fine or 1 year imprisonment or both.
If your name has been changed from that shown on your account number card,
please copy your name below exactly as it appears on that card.
16-8289-10
Back:
OLA
Your Social Security Account
IJO PRZ
If you want a statement of
your Federal Old-Age
Survivors Insurance Account,
fill out the other side of this
card.
Be sure to give your name
and account number exactly
as they are shown on your
account number card, in order
to make sure your account is
properly identified.
If you
have more than one account
number, give all of them.
It is not necessary for you
to pay anyone to aid you in
securing this information.
There is no charge for this
service.
Be sure to place a stamp
on this card before mailing
it to us.
SOCIAL SECURITY ADMINISTRATION,
CANDLER BUILDING,
GPO 16-8289-10
BALTIMORE 2, MD.
LINCOLN
