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Social Security Disability Monthly Wage Information

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If your earnings are close to the substantial gainful activity level (see 20 C.F.R. § 404.1574), documentation from your employer may be essential to show the Social Security disability examiner that you are not actually performing substantial gainful activity. Your W-2 form may work fine for last year, especially if there is no question concerning the dates you worked. If there is a question about the dates worked last year, you may need information from your employer.

If you are working in the current year and a recent paystub does not show all necessary information, you may need earnings information from the employer. This form will gather it.

Note that this form asks about vacation and sick pay. According to POMS DI 10505.010 C, only earnings paid as a result of actual work activity count. Thus, sick pay and vacation pay do not count for determining eligibility for Social Security disability benefits, although according to POMS DI 10505.010 D, bonuses do count.

To: ______________________________________________________

Re: ______________________________________________________

SSN: _____________________________________________________

Please show monthly gross income and income from vacation or sick pay for the months and years indicated:

Date: ________________________________ 
Signature: ________________________________

Title: ________________________________ 
Print Name: ________________________________

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