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Retirement, Survivors And Disability Insurance Supplement Security Income

Download and Print the SSA-3033

Request may not be processed if the form is incomplete or illegible.

Claim Number:
Social Security Number:
Worker's Name:
Dear Sir or Madam:
We are writing to you about__________________________________________________ .

Please assist us by completing the enclosed questionnaire. We are requesting this information in order to determine whether work activity is/was subsidized or was an unsuccessful work attempt under the Social Security rules. The information you provide will not be shared with other agencies and is in no way a negative reflection on the employee, or you as the employer.
Information About Subsidy A subsidy exists when an employer willingly pays more in wages than the value of the actual services performed. This is usually for humanitarian reasons. A subsidy can be reflected by giving the employee:
extra assistance,
full wages for lower quality or quantity than standard, or
fewer and/or easier duties than usual for that position.

Information about Unsuccessful Work Attempt

An unsuccessful work attempt may exist if the employee had frequent absences, performed unsatisfactorily, and worked for six months or less.
And much more...