OMB No. 0938-0787 Expires: 06/2023 REQUEST FOR ... - CMSMODIFIED BENEFIT FORMULA QUESTIONNAIREIMPORTANT SIGN AND RETURN THIS FORM IN THE ENCLOSED ...OMB No. 0938-0787 Expires: 06/2023 REQUEST FOR ... - CMS-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name as it appears on your Social Security card in the designated fields for First Name, Middle Initial, and Last Name.
3. Provide your Social Security Number (SSN) and Date of Birth. Ensure that you enter only one SSN per request.
4. Select the type of earnings information you need by checking the appropriate box. Specify the years requested for earnings information.
5. If you want the information sent to someone else, fill in their details in section 3, including their name and address.
6. Sign and date the form at the bottom, ensuring that if you sign with an 'X', two witnesses must also sign.
7. Review all entered information for accuracy before submitting your completed form to SSA within 120 days of signing.

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