Form SSA-112 Notification of a Social Security Number (SSN) to an Emp

Form Approved
Social Security Administration
OMB No. 0960-XXXX
Notification of a Social Security Number (SSN) to an Employer for Wage Reporting
Purposes
________________________________________________________________________
A. Employer information
________________________________________________________________________
Employer’s Name
____________________________________
Employer’s Mailing Address __________________________________
____________________________________
____________________________________
____________________________________

Employer’s Identification Number (EIN) ___________________
________________________________________________________________________
B. To be completed by the SSN applicant
________________________________________________________________________
I request that SSA notify my employer of my SSN upon assignment.
____________________________________
Printed Name
____________________________________
Signature
____________________________________
Date (MM/DD/YYYY)
C. For SSA use only
________________________________________________________________________
An SSN has been assigned and a Social Security card was mailed to the following person
who requested we notify you directly of the SSN.
First Name
Middle Name
Last Name
Social Security Number
NOTE: This notification may only be used for original SSN applications when SSA
has not yet assigned an SSN.

Social Security Administration
Notification of SSN to Employer for Wage Reporting Purposes
Please read these instructions carefully before completing this form.
When to Use
This Form

Use this form if you are applying for a Social Security
Number (SSN) and want SSA to notify your employer of the
SSN upon assignment.
Section A. Employer information
 Fill in the employer name, mailing address, and
Employer Identification Number (EIN).

How to Complete
This Form

Section B. To be completed by the SSN applicant
 Sign and date the form at the SSA office at the time
you apply for the original SSN.
Section C. For SSA use only
 The SSA field office employee will complete the name
and SSN of the person who signed in Section B. upon
assignment of the original SSN.
PRIVACY ACT NOTICE
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, authorizes us to collect the
information requested on this form. By signing this form, you authorize us to notify your
employer of your Social Security number (SSN), upon assignment, for the purpose of
wage reporting. Without your signature, we cannot complete your request to notify your
employer of the assigned SSN. We will not use this form for any other purpose.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets
the clearance 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 2 minutes to read the instructions, gather the facts, and answer the
questions. THE PERSON APPLYING FOR AN ORIGINAL SSN SHOULD BRING
THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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-112 (_-2009)