DECOR Notice One-Time Study

SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information

DECOR Study Earnings Report Questionnaire

DECOR Notice One-Time Study

OMB: 0960-0508

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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)


  1. What is your correct Social Security Number? _____________________


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


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



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


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


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


If yes, what is that number? ___________________________


  1. 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 ______


  1. 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: _______________________________________________________


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Author889123
Last Modified By889123
File Modified2010-07-26
File Created2010-07-26

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