DECOR Study Earnings Report Questionnaire - 0508

Social Security Administration OMB Approval No.

0960-0508

EARNINGS REPORT QUESTIONNAIRE

The earnings report had the following information:

Reported Employee Name SSN

Employer Name EIN

Wage Amount

1. What is your correct name? ______________ _______ ______________

(first) (middle) (last)

2. What is your correct Social Security Number? _____________________

3. What is your Date of Birth? __ __/__ __/__ __ __ __ (month, day, year)

4. Have you changed your name? Yes____ No____ Provide prior name:

5. How long have you worked for the employer shown? ______

6. If this company no longer employs you, what was your day last worked? _________________

7. Have you been assigned an Individual Tax Identification Number, also known as an ITIN? Yes ______ No ______

If yes, what is that number? ___________________________

8. Have you ever received a Social Security Statement of earnings from the Social Security Administration? Yes _____ No ______

If yes, did you review it to see if it contained all of your earnings? Yes ______ No ______

9. Have you ever had problems in the past with having your earnings correctly reported to the Social Security Administration? Yes ____ No _____

If yes, please explain the problem(s) you experienced: _______________________________________________________