SSA-L4002 original

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Form Approved

OMB No. 0960-0508

Social Security Administration

Retirement, Survivors, and Disability Insurance

Request for Employer Information

Social Security Administration

Data Operations Center

P.O. Box 39

Wilkes-Barre, PA 18767-0039

Date:

Sequence Number:

Employer Number:

We are writing to you about your Wage and Tax Statement (W-2) or Corrected Wage and Tax Statement (W-2c) for the employee shown below. Please complete the information on the back of this letter and return it to us promptly. We cannot put these earnings on the employee’s Social Security record until the name and Social Security number you reported agree with our records.

Employee’s Name:

Social Security Number:

Reported Earnings:

Tax Year:

The reasons the reported information does not agree with our records may include, but are not limited to:

• Typographical errors

• Incomplete or blank name reported

• Incomplete or blank Social Security Number (SSN) reported

• Name changes

This letter does not imply that you or your employee intentionally provided incorrect information about the employee's name or SSN. It is not a basis, in and of itself, for you to take any adverse action against the employee, such as laying off, suspending, firing, or discriminating against the individual. Any employer that uses the information in this letter to justify taking adverse action against an employee may violate state or Federal law and be subject to legal consequences. Moreover, this

letter makes no statement about your employee's immigration status.

For Spanish-speaking individuals: Esta carta no implica que usted ni su empleado intencionalmente proveyeron información incorrecta sobre el nombre o número de Seguro Social del empleado. El hecho de que usted haya recibido esta carta no constituye una razón, de por sí, para que usted tome alguna acción adversa contra el empleado, tal como suspenderlo, despedirlo o discriminar contra el individuo. Cualquier empleador que use la información en esta carta para justificar una acción adversa contra un empleado puede encontrarse en violación de la ley estatal o federal, y estar sujeto a enfrentar consecuencias legales. Además, esta carta no hace ninguna declaración sobre el estado de inmigración de su empleado.

Esta carta pide información sobre las ganancias que usted informó por su 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 EMPLOYER INFORMATION (Please Print-- Use Black Ink or #2 Pencil)

1. Name shown on the employee’s Social Security card:

FIRST M.I. LAST

2. Social Security number on the employee’s card:

3. Do the earnings reported belong to this employee? Yes No (Explain)

3. Has the employee ever used another name? No Yes (Give other names used)

FIRST M.I. LAST

3. Does the employee still work for you? Yes No (Give full last known address)

ADDRESS

---

CITY STATE ZIP

3. D aytime phone number where you can be reached

THIS IS WHAT YOU NEED TO DO

1. Compare the information shown above to your employment records.

2. If the records match, ask the employee to give you the name and Social Security number exactly as it appears on the employee's Social Security card. (While the employee must furnish the SSN to you, the employee is not required to show you the Social Security card. But, seeing the card will help ensure that all records are correct.)

3. If the employee's Social Security card does not show the employee's correct name or Social Security number, or if the employee needs to report a name change or replace a lost Social Security card, have the employee contact any Social Security office.

4. If you or the employee have been using an incorrect name or Social Security number, you must correct it.

5. Fill in the information above and return this letter in the enclosed envelope. (Do not attach a Form W-2c to this letter.)

If you have any questions, you may call us toll-free at 1-800-772-6270 from 7 a.m. to 7 p.m., Monday through Friday, Eastern time. If you call an office, please have this letter with you. It will help us to answer your questions.

W. Burnell Hurt

Associate Commissioner for

Enclosure: Central Operations

Envelope

See Next Page

DO NOT RETURN THIS PAGE

POINTERS FOR CORRECT REPORTING

1. The Internal Revenue code requires an employer to include each employee’s Social Security number when filing returns, such as the W-2 Wage and Tax Statements. The employer identification number must also appear on such returns.

2. Ask for the employee’s Social Security number and explain that the law requires the

employee to give the number although (s)he may be ineligible for benefits.

3. Include the middle initial if shown on the employee’s Social Security card.

Format: John C. Smith.

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 the employee credit for the correct amount of wages. You do not have to complete this letter. However, if you do not, we cannot give the employee credit for the correct amount of wages. 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.

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