The last time we brought
your case up-to-date was:
SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals
Form Approved
OMB No. 0960-0300
CLAIMANT'S WORK BACKGROUND
A. To be completed by Hearing Office
PLEASE PRINT
(Claimant and Social Security Number)
(Wage Earner and Social Security number)
(Leave blank if same as claimant)
B. To be completed by the claimant
- -
- -
Form HA-4633 (3-1994) ef (10-2004)
Issue Old Stock
If more space is needed,
use additional sheets.
DATES OF
EMPLOYMENT
(APPROXIMATELY)
FROM
NAME OF EMPLOYER AND
LOCATION OF EMPLOYMENT
DUTIES PERFORMED
Start with your most recent job, and list that and any work performed within the past 15 years.
TO
FROM
TO
FROM
TO
FROM
TO
The Social Security Act (sections 205(a), 702, 1631 (e)(1)(A) and (B), and 1869(b)(1) and (C), as appropriate)
authorizes the collection of information on this form. We will use the information on your work background to
help us decide if we need to obtain more information. You do not have to give it, but if you do not you may not
receive benefits under the Social Security Act. We may give out the information on this form without your
written consent, if we need to get more information to decide if you are eligible for benefits or if a Federal law
requires us to do so. Specifically, we may provide information to another Federal, State, or local government
agency which is deciding your eligibility for a government benefit or program; to the President or
Congressman inquiring on your behalf; to an independent party who needs statistical information for a research
paper or audit report on a Social Security program; or to the Department of Justice to represent the Federal
Government in a court suit related to a program administered by the Social Security Administration.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a