SSA-L3365 original

3365-04

Form Approved

OMB No. 0960-0508

Social Security Administration

Retirement, Survivors, and Disability Insurance

Request for Employee Information

Social Security Administration

Data Operations Center

P.O. Box 39

Wilkes-Barre, PA 18767-0039

Date:

Sequence Number:

Employer Number:

We need more information so that we can give you credit for your earnings from the company and for the year shown below. We cannot put these earnings on your Social Security record until the name and Social Security number reported to us match our records. Unless this problem is corrected, you may not get retirement, disability, survivors or other benefits that you are due.

Company Name:

Employee’s Name:

Social Security Number:

Reported Earnings:

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 your FormW-2(s) and your Social Security card.

• If the name and number shown on the Social Security card agree exactly with the information shown above, contact your local Social Security office so that we can find out why our records do not match what was reported for you by your employer. Do not mail this letter back to us.

• 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 reverse side of this letter, and mail it to us in the enclosed envelope. If you have been using an incorrect name or Social Security number, or your employer has been reporting earnings for you under an incorrect name or Social Security number, you must also correct this information with your employer.

IMPORTANT: THE FACT THAT YOU HAVE RECEIVED THIS LETTER DOES NOT, IN AND OF ITSELF, ALLOW YOUR EMPLOYER TO CHANGE YOUR JOB, LAY YOU OFF, FIRE YOU OR TAKE OTHER ACTION AGAINST YOU. IF YOU THINK YOUR EMPLOYER IS DISCRIMINATING AGAINST YOU BECAUSE YOUR NAME AND SOCIAL SECURITY NUMBER DO NOT MATCH OUR RECORDS, SEE THE ATTACHED INFORMATION ON IMPORTANT PROTECTIONS OF YOUR RIGHTS.

For Spanish-speaking individuals: Esta carta contiene información importante. Vea la página 3 para más detalles.

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Most problems with names and Social Security numbers that do not match our records are the result of mistakes and do not involve intentional fraud. We want to work with you and your employer to correct your earnings record and to make sure that you receive

credit for all of your work under the Social Security program.

Please fill out the following form if the name and number shown on your Social Security card do not agree with the information on page one of this letter. Please take this action now to make sure you receive any retirement, disability, survivors or other benefits owed

to you.

For Spanish-speaking individuals: Esta carta pide información sobre las ganancias que su empleador informó por usted. 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.

REQUEST FOR EMPLOYEE INFORMATION

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

First M.I. Last

2. S ocial Security number on your card:

3. D oes the amount of reported earnings on the front

of this letter match any Form W-2 you received for the Yes No (Explain)

tax year shown?

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

First M.I. Last

3. Daytime phone number where you can be reached __ __ __ __ __ __ __ __ __ __

­

NOTE: Do NOT send a copy, or original, of a Form W-2c with this letter.

See Next Page

KEEP THIS PAGE--IT INCLUDES IMPORTANT INFORMATION

• Your employer may not take action against you based on this letter.

If you think that any action against you is related to labor union activities or union organizing activities, you may contact the National Labor Relations Board (NLRB), an agency of the U.S. government (www.nlrb.gov). Check your local directory for the nearest NLRB office in your area.

• If you think that any action against you is related to your race, color, sex, religion, national origin, age or disability, you may call the Equal Employment Opportunity Commission (EEOC) toll-free at 1-800-669-4000, or 1-800-669-6820 (TDD for the deaf or

hard of hearing), or visit the website at www.eeoc.gov.

• If you have questions or concerns about unfair practices by your employer that may be related to your national origin or citizenship status, you may call the Office of Special Counsel for Immigration-Related Unfair Employment Practices toll-free at

1-800-255-7688, or 1-800-237-2515 (TDD for the deaf or hard of hearing). Within the Washington, D.C., metropolitan area, call 202-616-5594.

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For Spanish-speaking individuals:

GUARDE ESTA CARTA-CONTIENE INFORMACIÓN IMPORTANTE

Su empleador no puede tomar acción en su contra basándose en esta carta.

• Si usted piensa que cualquier acción en su contra está relacionada con las actividades del sindicato de trabajadores, usted puede ponerse en contacto con la Junta Nacional de Relaciones del Trabajo (NLRB, siglas en inglés), una

agencia del gobierno de los Estados Unidos (www.nlrb.gov). Busque la oficina más cercana de la Junta Nacional de Relaciones del Trabajo en su directorio local.

• Si usted piensa que cualquier acción en su contra está relacionada con su raza, color, sexo, religión, origen nacional, edad o incapacidad, puede llamar gratis a

la Comisión de Igualdad de Oportunidades de Empleo (EEOC, siglas en inglés)

al 1-800-669-4000 ó 1-800-669-6820 (TDD para las personas sordas o con problemas auditivos), o visitar www.eeoc.gov en el Internet (sólo disponible en inglés).

• Si usted tiene preguntas o dudas sobre prácticas injustas por parte de su empleador, que pueden estar relacionadas con su origen nacional o estado legal, puede llamar gratis a la Oficina del Consejero Especial para Prácticas de Empleo Injustas Relacionadas a la Condición de Inmigrante al 1-800-255-7688 ó 1-800-237-2515 (TDD para las personas sordas o con problemas auditivos). Dentro del área metropolitana de Washington, D.C., llame al (202) 616-5594.

El hecho de que usted haya recibido esta carta no constituye una razón, de por sí, para que su empleador lo cambie de trabajo, suspenda, despida o tome alguna acción adversa en su contra.

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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:

If you need an interpreter to conduct Social Security business, we will supply one on request, free of charge. If you want us to supply the interpreter, please call

1-800-772-1213 before you come to the office and tell us what language you prefer to speak.

Si usted necesita un intérprete para tramitar sus asuntos con el Seguro Social, le podemos proveer uno, libre de costo. Si usted desea que proveamos un intérprete, por favor llame al 1-800-772-1213 antes de venir a la oficina y díganos en que idioma prefiere hablar.

W. Burnell Hurt

Associate Commissioner for

Central Operations

Enclosure:

Envelope

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 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.

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