SSA-L725 (current)

Form Approved
OMB No. 0960-0034

SOCIAL SECURITY

Refer to:

Date:
•
Social Security
Number
Worker's Name:
Telephone:
Area Code:

So that we may determine the above-named person's eligibility for Social Security benefits,
please furnish the amount of gross wages earned by the employee in each of the months
checked below. If no wages were earned in a month, show "none."
Please note that we need to know the amounts earned for services performed within the
calendar month, regardless of the amounts paid. If the employee received cash tips, include
the amount in the totals for the month.
We appreciate your cooperation in furnishing this information. An envelope requiring no
postage is enclosed for your convenience.
Sincerely yours,
Enclosure
If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
January

$

April

July

$

October $

$

February

May

August

November

March

June

September

December

See other side for additional years (check if applicable).
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 30 to 50 minutes to
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
EMPLOYER
SIGNATURE

AREA CODE AND TELEPHONE NO.
TITLE

DATE
Form SSA-L725-F3 (08-2009) EF (08-2009)
Destroy Prior Editions

If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
January

$

April

July

$

October $

$

February

May

August

November

March

June

September

December

If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
January

$

April

July

$

October $

$

February

May

August

November

March

June

September

December

If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
January

$

April

July

$

October $

$

February

May

August

November

March

June

September

December

If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
January

$

April

July

$

October $

$

February

May

August

November

March

June

September

December

I declare under penalty of perjury that I have examined all the information on this form,
and on any accompanying statements or forms, and it is true and correct to the best of my
knowledge.
SIGNATURE

TITLE

DATE

Form SSA-L725-F3 (08-2009) EF (08-2009)

Privacy Act Statement
Collection and Use of Personal Information
20 CFR 404.703 authorizes us to collect this information. The information you provide will be used to determine
your employee's eligibility for Social Security Benefits.
The information you furnish on this form is voluntary. However, we need your cooperation to assure that the
above-named person's wage record is accurate and that we can correctly determine eligibility for Social Security
benefits.
We rarely use the information you supply for any purpose other than for determining continued eligibility. 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 of Social
Security programs.
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.
Additional information regarding this form, routine uses of information, and our programs and systems, is available
on-line at www.ssa.gov or at your local Social Security office.

Form SSA-L725-F3 (08-2009) EF (08-2009)