Dorian Mayhew Rothschild 60 Arthur St.

San Rafael, CA 94901 May 09, 2012

Wilkes-Barre Data Operations Center P.O. Box 7004 Wilkes-Barre, PA 18767-7004 Dear Sir or Madam: I would like to receive a free statement of earnings and an estimate of my Social Security benefits. To enable you to process my request, the following information is provided: 1. Name as shown on the Social Security card: Dorian Mayhew Rothschild 2. Social Security Number as shown on the card: 123-45-6789 3. Date of birth: March 15, 1977 4. Other Social Security Number(s) used: a. b. 5. Sex: Male 6. Other names used (including maiden name): NONE 7. Earnings: a. Actual earnings for last year were: $74,000.00 b. Estimated earnings for this year are: $68,000.00 8. The age at which I plan to retire: 67 9. Estimate of future average annual earnings (in today's dollars): $85,000.00 10. Please forward the requested information to the following person: Bryan Burgland 123 Main St. Mill Valley, CA 94941 Please contact me at the above address if you have any questions or need additional information. I can be contacted by phone at (415) 475-1763 or (415) 876-0543.

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I am asking for information about my own Social Security record. I understand that if I deliberately request information under false pretenses, I may be guilty of a federal crime and could be fined and/or imprisoned. I authorize you or your contractor to send the statement of earnings and benefit estimates to the person named in Item 10. Sincerely,

Dorian Mayhew Rothschild

This is a RocketLawyer.com Legal Document