Information Collection

Employer Verification of Earnings After Death

IC 9361 under ICR 201003-0960-004 · OMB 0960-0472.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0472 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L4112 Employer Verification of Earnings After Death	Form
SSA-L4112 Employer Verification of Earnings After Death SSA-L4112 Final.pdf	Form

IC Title:

Employer Verification of Earnings After Death

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.822 20 CFR 404.821

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4112	Employer Verification of Earnings After Death	SSA-L4112 Final.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	8,333	8,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.