Form SSA-L4112 Employer Verification of Earnings After Death

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Employer Information
Social Security Administration
Data Operations Center
P.O. nox 3 3 %b
Wilkcs Rarrr, PA 118767-0080
1)atc:

Sequence Number:

h p l o y e r Number:
We arc writing td) yo11 a b u ~ tyour
t
W a g e and Tax Statement (W-2)
far the employee
shown beluw. Thr~amount you reported appears to be payments made after the
employees stopped working for you and is not covered by Social Security.
Employee's Name:
Social Security Number:
Reported Earnings:
Tax Year:

Please fill in the information on the back of this form and mail it to u s in the enclosed
envelope. If possible, vcrlfy the number on the empiovee's Social Security card :xnd
check your records tfi give u s the irtformation requested.
[f you have any questions about this lcttcr, you may call us toll-free a t 1-800-772-6270
from 7:00 a.m. tc~7:00p,m. Eastern Standi~rd'rime.

Carolyn L. Simmons
Associate Cornrnis&~-~er
for Central Operations

Enclosure:
Envcahpe

Social Security Request for Employment Information
1 . 1)trc.s the crnploycc! still work for you?
((;it?(. 1,nst Kftou:nAcldrc8s)

Yes

No

Yes

2. Did employment end because the employee died?

No

ff employment ended because the employee died. refund the emp1c)yee's share of
the Social Secursity taxes to t h e emyloyce's estate or next of kin, and obtain a
receipt. Then, ask for a refund of the employcr and employee Social Security taxes
from the Internal Revenue &Service(IRS),For details about how to obtain a refund,
contact t h c IKS (there are time limits for scekit~ga refund from the IRS).
Earnmgs paid 1.1 deceased employee nftcr t h e year of death arc not wages subjec:t to
Social Security ur Medicare taxes and should be reported on Fcirm lOtftl. (Sce IHS
I\'-2 reporting instructions)
3. If tho onrnlnga shown above arc earnings covercd by Social Security, print the
name a n d number shown on the employeeta Social Security c a r d and the tax
year af these enrnlngs:

Sewurl S P C ~ Kurnber
III~~

m-a-

Tax Ycar

u

THE PRIVACY ACT
Section 206(a) of the Social Security Act allows us to ask for the information on thw letter
7?ie information you give us will be ileed to give tho employee credit for the correct ;tmi>u~it
of
wages, You do not have to complete t h k letter, howcvor, if you don't: we can't give thc
empluyec credit for the correct amount of wages.

ltcvenue Servico for tax adminiatl.at~onpurposes
or t,o t h e l>epartment of Justice for invest~gatingand prosecuting violations of the Soc1:11
Sttcurity Act. We may also use the ir~formationyou give us when we match ~ e c o r d by
s
cumptzter. Match~ngproKramn compare our records with those of other Federal, Stats or local
ugencics. Many agrtncien may rise matching programs tu find or prove that a parson quallfleu
for beztefib paid by the FodcraI government. Tho law allows u~ to drr thlv even lf you do nut

Ci'u may g ~ v thls
e
tnformatlon to the Internal

agree to

it.

Explanations abuut these and ather reasons why information you providc us may be used or
given out, are available in the Social Security offices. If you want to learn more about th~s,
contact any Social Security office.
PAPERWORK REDUCTION ACT

'I'hie tnfcirination collection meets the requirements of44 U.S.C. 3507, as amended by sclcttorr
2 af the Pti~erworkReduction Act of 1995. Yoti do not need to answer thcsc questions unless
wc display a vakd Office of b1snagernent and ISudgct control number. Wc catlmate that ~tw ~ l l
take about 10 nlinutcs to mad the ~nstructinnn.g;lt,ht?r thc facts. and answer the questions.
Yorc. nlrzy srrtd corttrn~rrison our ttrric* e t l t ~ r n r ~nkjr-t!
te
to: SSA, 6.101S e c u r k l ~Ultd.. B ~ b t i r n o w ,
MI1 21335-6401. Send o&eon~rnents relating to our t i m e estimate t o t h i s arldrrse, nut
the completed form.