Form SSA-95-SM Employer Questionnaire--SSA Has No Record of Employer Re

Date:

MM/DD/YYYY

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EMPLOYER QUESTIONNAIRE
SSA HAS NO RECORD OF EMPLOYER REPORT

IRS records show that you paid taxes on the wages that appear below. However, SSA does not have a
record of processing your Forms W-2 and W-3 for these wages. IRS requires you to send Forms W-2 to
SSA.

IRS Data (Forms, 941, 943, 944 or Schedule H) for Tax Year: YYYY
EIN: 99-9999999
Employer Name: Employer Name
Employee Soc. Security Wage Totals:
Employee Soc. Security Tip Totals:
Employee Medicare Wage/Tip Totals:

$999,999.00
$999,999.00
$999,999.00

CHECK AND COMPLETE
Check and complete any items that apply to your wage report for the tax year shown above. If you send a
wage report that shows a different total from the amount shown above, please explain why in number 6.
1. ( ) I did not file Forms W-2 with SSA. I am now taking the following action (check one):
( ) Enclosing the original Copy A of Forms W-2 and W-3, or a magnetic media report, or
( ) Sending SSA an electronic file.
2. ( ) I filed Forms W-2 under the EIN shown above. I am now taking the following action for the wages I
previously reported (check one):
( ) Enclosing legible copies of Forms W-2 and W-3, or a magnetic media report, or
( ) Sending SSA an electronic file.
3. ( ) I filed Forms W-2 under EIN __________, rather than the EIN shown above. (Attach legible copies
of Forms W-2 and W-3.)
4. ( ) I filed but cannot locate my copies of Forms W-2 and W-3. (Attach an explanation of why you
cannot locate the records and a list of all names, total wage amounts and Social Security numbers
for your employees for the year shown above.)

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5. ( ) I was not required to file Forms W-2 with SSA, as I was self-employed. (Attach a legible copy of
Form 1099 or 1040 with a Schedule SE or Schedule C that shows SE tax.)
6. ( ) Other ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

_________________________________________________________ ( ) ______________________
Your Name and Title
Daytime Phone, with area code
INFORMATION ABOUT THE DATA YOU SEND SSA
The name, Social Security number and wage amounts on the Forms W-2 must be readable and complete. If
we cannot read all information on the documents you submit, or if any of these items are missing, we
cannot add the wages to the employee's wage record. If you need blank copies of the Forms W-2 or W-3,
call IRS at 1-800-829-3676. If your copies of the Forms W-2 are illegible, please prepare duplicates on
blank copies of the Forms W-2. Make sure the Forms W-2 show the year for which the wages are being
reported.
Note: If you send 250 or more wage items to us, you must use magnetic media or file your wage reports
electronically in accordance with SSA’s Magnetic Media Reporting and Electronic Filing (MMREF)
publication Publication 42-007: Specifications for Filing Forms W-2 Electronically (EFW2). To get more
information, go to our website at www.socialsecurity.gov/employer or call SSA's Employer Reporting
Branch at 1-800-772-6270 from 7:00 A.M. to 7:00 P.M., Eastern time, Monday through Friday.
RETURN THIS QUESTIONNAIRE
Please send all requested information to:
Social Security Administration, Metro West
P.O. Box 33021
Baltimore, Maryland 21290-3021
Do not send cash, checks or money orders to SSA. Tax payments are payable to the Internal Revenue
Service.

SSA-95-SM (11-06)

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