DECOR Notice One-Time Study

Social Security Administration OMB Approval No.

0960-0508

WAGE REPORT QUESTIONNAIRE

INFORMATION ON WAGE REPORT

Employee ___________________ , _______________ ________

(last name) (first name) (middle)

SSN______________________ Wages____________________

1. Is the W-2 information listed above correct for this employee? Yes____ No____

If no, what is incorrect? _______________________________________________

_________________________________________________________________

2. Have you received any previous correspondence from the Social Security Administration regarding problems with your wage reports for this employee? Yes _____ No _____

3. We show your EIN as _________________. Is this correct?

Yes _____ No _____ If no, please provide EIN __________________________

4. What is the employee’s date of birth? __ __/__ __/__ __ __ __ (month, day, year)

5. Have you retained copies of any identification (ID) that the employee on file may have provided ? Yes _____ No _____

6. Do the name and Social Security number on the application match the ID the employee provided? Yes _____ No _____

If no, please explain the difference ____________________________________

_________________________________________________________________

7. Did you see the employee’s Social Security card? Yes ______ No ________

If yes, did you make a copy of it? Yes _____ No ______

8. Does this employee still work for you? Yes _____ No _____

If no, when did the employee leave? ___________________________________

9. Do you have a current address for the employee? Yes ______ No ______

If yes, please provide the address :

__________________________________________________________________

10. Did the employee change his or her name while employed by you?

If yes, please list old and new names: __________________________

11. Has the employee provided a different Social Security number or Tax ID number (ITIN) while employed by you?

If yes, please list previous Social Security number and current one: