if7

Standard FOrDl No. 115

Revised November 1951

Prescribed by G~eral Scr"ices

AdmWlistration

GSA Re~. 3-IV-I06

WH03

REO~.
FOR AUTHORITY
TO DISPOSE OF RECORDS
(See Instructions

TO:

on Reverse)

GENERAL SERVICES ADMINISTRATION,

NATIONAL

ARCHIVES

AND RECORDS

SERVICE,

WASHINGTON,

D.C.

20408

1. FROM (AGENCY OR ESTABLISHMENT)

NOTIFICATIO~

Department of Health, Education,

2. MAJOR SUBDIVISION

IN ACCORDANCE WITH THE PROVISIONS OF PUBLIC

LAW 91-287
DISPOSAL OF ITHtS MARKED "DISPOSAL
APPROVED" IS AUTHORIZED.

Social Security Administration

Bureau of District Office Operations

3. MINOR SUBDIVISION

and Bureau

of Retirement

TO AGENCY

and Welfare

and Survivors

Insurance

4. NAME OF PERSON WITH WHOM TO CONFER

Arthur J. Benner

5 TEL EXT

;30~45;71

6. CERTIFICATE OF AGENCY REPRESENTATIVE:

I hereby certiCy that I am authorized
schedule
A

oC ~

palle. are proposed

The
r e c or d s have
ceased to have sufficient value to warrant
Curther retention.

to act Cor the head oCthis agency

Cor disposal

Cor the reason indicated:

In matters
("X"

pertaining

to the dilpotlal oCrecordl,

and that the recordl

The records will cease to have sufficient value

to warrant Curther retention on the expiration

oC the period of time indicated or on the occur-

-,!...-o'__
....::theevent specified.

12/7/73

Dept. Records Mgt. Officer

(Date)
7.
ITEM NO.

delCribed In thla liat or

only one)

(Title)

9.

8. DESCRIPTION OF ITEM
(WITH INCLUSIVE DATES OR RETENTION PERIODS)

POST-ENTITLEMENT

10.

SAMPLE OR
JOB NO.

ACTION TAKEN

SOURCE DOCUMENTS

The files described in this schedule are source

documents accumulated as a result of reporting and
handling post-entitlement events by beneficiaries and
the Social Security Administration.
For the purposes
of this schedule, a post-entitlement event is defined
as any action requiring a change in a beneficiary's
account after initial entitlement.
These records
accumulate in SSA district and branch offices and in
SSA program centers.
1.

Work Report Records

These files consist of Form SSA-1425, Reporting Card,
and comparable documents used by beneficiaries or
their representatives to report current year work and
earnings information to the Social Security Administration. Excluded from this definition are Annual

Reports of Earnings submitted pursuant to Section 203

(h) and (i) of the Social Security Act.
Retain at the point of receipt for three (3) months
and then dispose of the source document.

r_ copIe., Iach ..ll ...

I j-te"
d ...... , 10 ... nIomlH"

t ....

Nlld... oJ .clai

.........

Reco ..... IIorrice

2SPOSAJ. APPROV:!'