Form SSA-4156 Employee Identification Statement

Form Approved
OMB No. 0960-0473

Social Security Administration

See Paperwork Reduction
Act/Privacy Act Notice on Reverse

Employee Identification
Statement
1.)

Is the Social Security number on the letter the same as on your
records?

•

D

Yes

D

No

If "No," what do your records show?

2.)

Full Name of Employee

3.)

(a) Date of Birth

(b) Place of Birth

4.)

(a) Father's Name

(b) Mother's Name

5.)

Last Known Address of Employee

6.)

(a) Physical Description (please provide a copy of photo ID if available)

(b) Distinguishing Characteristics

7.)

Name and Address of Nearest Relative

8.)
Dates of Employment With Your Company

9.)

Business Name of Employer

10.)

Employer's Federal Identification Number

11.)

(a) Street Adress of Employer

(b) City

Form SSA-4156 (l0-2007) ef (l0-2007)

(c) State

•

To

From

(d) Zip Code

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12.)

For signature comparison, please send a photocopy of the individual's form W-4, if available.
Signature (First name, middle initial, last name) (Write in ink)

Date (month, day, year)

SIGN~
HERE

Telephone Number (include Area Code)

Print Name

Title

Privacy Act Notice
This report is authorized by law 20 CFR 404.702. While your response is voluntary, your cooperation
is needed to assure that the above named person's wage record is accurate and that a correct
determination of eligibility for Social Security benefits is made.
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.
These and other reasons why information about you may be used or given out are explained in the
Federal Register. If you want to learn more about this, contact any Social Security office.

See Revised PRA Attached
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget control number.
We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not
the completed form.

Form SSA-4156 (l0-2007) ef (l0-2007)

Page 2

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.