Form SSA-4156 Employee Identification Statement

Fonn Approved
Social Security Administration

OMB No 0960-0473

See Paperwork Reduction
Act/Privacy Act Notice on Reverse

Employee Identification
Statement
1.)

Is the Social Security number on the letter the same as on your
records?
~

0

Yes

0

No

If "No," what do your records show?

2.)

Full Name of Employee

3.)

(a) Date of Birth

(b) Place of Birth

4.)

(a) Father's Name

(b) Mother's Name

5.)

Last Known Address of Employee

6.)

(a) Physical Description (please provide a copy of photo ID if available)

(b) Distinguishing Characteristics

7.)

Name and Address of Nearest Relative

8.)

To

From
Dates of Employment With Your Company

9.)

Business Name of Employer

10.)

Employer's Federal Identification Number

11.)

(a) Street Adress of Employer

(b) City

Form SSA-4156 (10-2007) ef (1 0-2007)

(c) State

~

(d) Zip Code

Page 1

12.)

For signature comparison, please send a photocopy of the individual's form W-4, if available.
Signature (First name, middle initial, last name) (Write in ink)

Date (month, day, year)

SIGN~
HERE

Telephone Number (include Area Code)

Print Name

Title

Privacy Act Notice
See Revised Privacy Act Statement Attached
This report is authorized by law 20 CFR 404.702. While your response is voluntary, your cooperation
is needed to assure that the above named person's wage record is accurate and that a correct
determination of eligibility for Social Security benefits is made.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other federal, State, or local government agencies. Many
agencies may use matching programs to find or prove that a person qualifies for benefits paid by the
Federal government. The law allows us to do this even if you do not agree to it.
These and other reasons why information about you may be used or given out are explained in the
Federal Register. If you want to learn more about this, contact any Social Security office.

See Revised PRA Statement Attached
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 ofthe 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 5 minutes to read the instructions, gather the facts, and answer the
questions. 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.

Form SSA-4156 (l0-2007) ef (l0-2007)

Page 2

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Title 20 CFR 404.702 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to assure that a person’s wage record is
accurate and make a correct determination of eligibility for Social Security benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from assuring that a person’s wage record is accurate and prevent us
from making a correct determination of eligibility for Social Security benefits.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing eligibility benefits. 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. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
We may also use the information you provide 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 or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Earnings Recording and Self-Employment Income System, 60-0059 and Master
Beneficiary Record, 60-0090. These notices, 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.

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 5 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.