Statement of Employer

ICR 200903-0960-002

OMB: 0960-0030

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2009-04-09
Supporting Statement A
2009-06-12
IC Document Collections
IC ID
Document
Title
Status
43689 Modified
ICR Details
0960-0030 200903-0960-002
Historical Active 200606-0960-001
SSA
Statement of Employer
Revision of a currently approved collection   No
Regular
Approved without change 10/02/2009
Retrieve Notice of Action (NOA) 06/12/2009
  Inventory as of this Action Requested Previously Approved
10/31/2012 36 Months From Approved 10/31/2009
925,000 0 925,000
308,333 0 308,333
0 0 0

SSA uses Form SSA-7011-F4 to substantiate allegations that earnings posted to the individual’s security record are incorrect, wages paid to the individual do not appear in SSA’s records of earnings, or the individual has no proof of said earnings. SSA uses the information received on this form to process claims for social security benefits and to resolve discrepancies in the individual’s social security earnings record. We only send Form SSA-7011-F4 to employers if we deem it necessary; in many situations, we are able to locate the earnings information within our records, without having to contact the employer. The respondents are certain employers who can verify wage allegations made by the wage earners.

US Code: 42 USC 405 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  74 FR 15808 04/07/2009
74 FR 27379 06/09/2009
No

1
IC Title Form No. Form Name
Statement of Employer SSA-7011-F4 Statement of Employer

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 925,000 925,000 0 0 0 0
Annual Time Burden (Hours) 308,333 308,333 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$2,849,000
No
No
Uncollected
Uncollected
No
Uncollected
John Biles 410 965-3758 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/12/2009


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