Current SSA-L3231-C1

Form Approved

OMB No. 0960-0505

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Employer Information
Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes Barre, PA 18767-0039

•

Date:
Sequence Number:
Employer Number:
We are writing to you about your Form W-2, Wage and Tax Statement, for the employee

shown below. Our records show that the employee is a young child. Therefore, we need

your help to resolve some questions before we can add the wages to the employee's earnings

record.

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 us in the enclosed

envelope. If possible, verify the number on the employee's Social Security card and check

your records to give us the information requested.

If you have any questions, you may call us toll-free at 1-800-772-6270 from 7:00 a.m. to

7:00 p.m. Eastern Standard Time.
W. Burnell Hurt
Associate Commissioner
for Central Operations

Enclosure:
Envelope

SPrinted on recycled paper

(See Reverse)

Form SSA·L3231-Cl (4-99)
Use Prior Editions

Page 2

Social Security Request for Employee Information
1. Please print the full name as shown on the Social Security card:

--.lID L--I_ _ _ _

Name:lL.--_ _
FIRST

---I

M.I.

LAST

2. Enter the Social Security number from your records:

1I 'I-OJ-I 1 1 1 1
3. Enter the employee's date of birth: OJ OJ OJ and Sex DD
Social.Security'Number:1

Month

Day

Year

M

F

4. What is the latest address you have on file?

5.

What was the employee's job?

The Privacy ActJPaperwork Reduction Act Statement
Section 205(a) of the Social Security Act allows us to ask for the information on this letter. The
information you give us will be used to give the employee credit for the correct amount of wages.
You do not have to complete this letter, however, if you don't, we can't give the employee credit
for the correct amount of wages.
We may give this information to the Internal Revenue for tax administration purposes or to the
Department of Justice for investigating and prosecuting violations of the Social Security Act.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security offices. If you want to learn more about this, contact
any Social Security office.
PAPERWORK REDUCTION ACT NOTICE AND TIME IT TAKES STATEMENT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is
in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of
1995. We may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB control number. We estimate that it will take you
about 10 minutes to complete this form. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form.

Form SSA-L3231-Cl (4-99)