SSA-L2765 original

2765-04

Form Approved

OMB No. 0960-0508

Social Security Administration

Retirement, Survivors, and Disability Insurance

Request for Self-Employment Information

Social Security Administration

Data Operations Center

P.O. Box 39

Wilkes-Barre, PA 18767-1765

Date:

Sequence Number:

Employer Number:

We need more information about self-employment earnings reported to us by the Internal Revenue Service. Please complete the information on the back of this letter and return it to us promptly. We cannot put these earnings on your Social Security record until the name and Social Security number reported agree with our records.

Name:

Social Security Number:

Reported Net Earnings from Self-Employment:

Tax Year:

THIS IS WHAT YOU NEED TO DO

1. If your Social Security card does not show your correct name or Social Security number, or if you have lost your Social Security card, please call our toll-free number, 1-800-772-1213, or contact your local Social Security office.

2. Compare the information shown above to the Schedule SE of your tax return and your Social Security card.

3. If the name and number shown on the Social Security card:

• Do not agree with the information shown above, fill in the requested information on the back of this letter. Then mail this letter to us in the enclosed envelope.

• Agree exactly with the information shown above, contact your local Social Security office. Do not mail this letter back to us.

4. Make sure that your future tax returns have your correct name and Social Security number.

Si usted necesita una traducción de esta carta, por favor llámenos al número de teléfono gratis, 1-800-772-1213, de 7 a.m. a 7 p.m. de lunes a viernes.

Please See Reverse

REQUEST FOR SELF-EMPLOYMENT INFORMATION

1. Name shown on your Social Security card (Please Print-- Use Black Ink or #2 Pencil)

First M.I. Last

2 . Social Security number on your card:

3. Were the earnings shown on the front of this letter reported on your (joint/individual) tax

return?

If No, explain _________________________________________________________________

_______________________________________________________________________________

If Yes, do the earnings reported belong to: You Your spouse (Please check one)

Spouse’s Name:

First M.I. Last

Spouse’s SSN:

4. Have you ever used another name? No Yes (Give other names used)

First M.I. Last

First M.I. Last

5. D aytime phone number where you can be reached

If you have any questions, you may call us toll-free at 1-800-772-1213. We can answer most questions over the phone. You can also write or visit any Social Security office. If you do call or visit an office, please have this letter with you. The office that serves

your area is located at:

W. Burnell Hurt

Associate Commissioner for

Central Operations

Enclosure:

Envelope

See Next Page

DO NOT RETURN THIS PAGE

THE PRIVACY ACT

Section 205(a) of the Social Security Act allows us to ask for the information on this letter. The information you give us will be used to give you credit for earnings reported. You do not have to give us this information. However, without the information we may not be able to give you credit for wages earned. We may give this information to the Internal Revenue Service for tax administration purposes or to the Department of Justice for investigating and prosecuting violations of the Social Security Act.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT STATEMENT

This information collection meets the clearance requirements of 44 U.S.C. section 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 10 minutes to read

the instructions, gather the necessary facts, and answer the questions.

2765-04