Federal Benefits Unit Inquiry Form

Select Inquiry Reason:*

Worker's Information

Last Name:*

First Name:*

Year of Birth:*

Last 4 Digits of Social Security Number:*

Claimant's Information (optional)

If other than worker, such as wife, husband, child, widow, ex-spouse

Last Name:

First Name:

Year of Birth:

Last 4 Digits of Social Security Number:

Contact Information:

E-mail Address:*

Enter Email Confirm Email

Telephone Number:*

Cell Phone Number:*

Address

Street Address 1:*

Street Address 2:

City:*

Postal Code:*

Untitled*

Remarks:*

The information you provide is used solely by the Federal Benefits Unit. In order to process certain types of requests, we may have to ask for your Social Security Number (SSN), your date of birth, your banking information and other information, please follow instructions on the Frequently Asked Questions for required information. You may decline to provide such information, but that could inhibit our ability to answer your questions or assist you with your request. Any information provided on our web form is not retained and is used only in order to process your current request or answer your current questions. The Federal Benefits Unit works in accordance with SSA procedures as well as the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) and the Privacy Act of 1974. You can read our full privacy statement at http://www.socialsecurity.gov.

Emails and Privacy:

Email is not secure and any information you provide on this online inquiry form cannot be guaranteed safe from potential loss. If you choose to send us any Personally Identifiable Information in your email inquiry, it will be removed from the email before we send our reply.