Form SSA-L4112 Employer Verification of Earnings After Death

See revised
Privacy Act and
Paperwork
Reduction Act
Statements below.

Attachment 1
Privacy Act Statement
Social Security Request for Employment Information
Sections 205(a), 205(c)(2) and 233 of the Social Security Act (40 U.S.C. § 405 and 433), and the
Federal Records Act of 1950 (64 Stat. 583), authorizes us to collect the information contained on
this form. The information you provide will be used to give the employee credit for the correct
amount of wages he or she earned in a given tax year. Completion of this form is voluntary.
However, failure to provide all or part of the requested information may affect the processing of
this form and could prevent the employee form acquiring his or her correct earnings information.
We rarely use this information provided on this form for any other purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. As a quarterly record detail file to provide data in wage investigation cases;
2. As a primary working record file of all SSN holders;
3. To record the latest employer of a wage earner;
4. To provide information to employers/former employers for correcting or reconstructing
earnings records and for Social Security tax purposes; and,
5. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
This information may be provided to the Internal Revenue Service for tax administration
purposes or the Department of Justice for investigating and prosecuting violations of the Social
Security Act. In addition, we may also use this information you provided in computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally-funded and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Earnings Recording and Self-Employment Income System, Social Security
Administration Office of Systems, 60-0059. The notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security Office.

SSA will insert the following revised PRA Statement 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. SEND OR
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.