Form SSA-95-SM Employer Questionnaire--SSA Has No Record of Employer Re

Date: MM/DD/YYYY

Form Approved
OMB No. 0960-0432

EMPLOYER QUESTIONNAIRE
SSA HAS NO RECORD OF EMPLOYER REPORT
The IRS records show that you paid Social Security and/or Medicare taxes on the wages that appear
below. However, SSA does not have a record of your Forms W-2 and W-3 for these wages. The IRS
requires you to send Forms W-2 to SSA.

IRS Data 941, 943, 944 or Schedule H (Form 1040 Household Employment Taxes) electronic and/or
paper returns) for
Tax Year: YYYY
EIN: 99-9999999
Employer Name: Employer Name
Employee Soc. Security Wage Totals:
Employee Soc. Security Tip Totals:
Employee Medicare Wage/Tip Totals:

$999,999.00
$999,999.00
$999,999.00

CHECK AND COMPLETE
Check and complete any items that apply to your wage report for the tax year shown above. If you send a
wage report that shows a different total from the amount shown above, please explain why in number 6.
1. ( ) I did not file Forms W-2 with SSA. I am now taking the following action (check one):
( ) Encloseding is the original Copy A of paper Forms W-2 and W-3, or
( ) Sending SSA an electronic file.
Caution: You must identify this as a reconciliation file when you submit it! Enclose the
electronic receipt showing the Wage File ID (WFID) as proof of filing. If you are filing
electronically, be sure to check the box indicating the submission is in response to a reconciliation notice.
When you return this questionnaire, include a copy of the Business Services Online (BSO) receipt
showing the wage file identifier (WFID) as proof of filing.
2. ( ) I filed Forms W-2 under the EIN for the TY shown above. I am now taking the following action for
the wages I previously reported (check one):
( ) Encloseding are legible copies of paper Forms W-2 and W-3, or
( ) Sending SSA an electronic file. Enclosed is a copy of the Business Services Online (BSO) receipt
showing the wage file identifier (WFID) as proof of filing.

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SSA-95-SM (04-11)

Caution: You must identify this as a reconciliation file when you submit it! Enclose the
electronic receipt showing the Wage File ID (WFID) as proof of filing.
3. ( ) I filed Forms W-2 under EIN __________, rather than the EIN shown above. Attach legible
copies if on paper. Enter the Wage File ID (WFID) if electronic (or other proof of filing if a third-party,
such as a payroll service e-filed for you).
4. ( ) I filed but cannot locate my copies of Forms W-2 and W-3. I am now taking the following action
(check one):
( ) Encloseding are duplicate copies of paper Forms W-2 and W-3, or
( ) Sending SSA an electronic file.
Caution: You must identify this as a reconciliation file when you submit it! Enclose the
electronic receipt showing the Wage ID (WFID) as proof of filing.
See “Caution” shown under Item #1 above.
5. ( ) I was self-employed. not required to file Forms W-2 with SSA, as I was self-employed. (Attach a
legible copy of
Form 1099 or 1040 with a Schedule SE or Schedule C that shows SE tax.)
( ) I was not required to file Forms W-2 with SSA. Attached are legible copies of Schedule SE or
Schedule C that show SE tax.
( ) I had employees working for me during the year. Attached are legible copies of Forms W-2 for
those employees.
6. ( ) Other ________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
________________________________________
Your Name and Title

( ) ______________________
Daytime Phone, with area code

INFORMATION ABOUT THE DATA YOU SEND SSA
The name, Social Security number, and wage amounts on the Forms W-2 must be readable and complete.
If we cannot read all information on the documents you submit, or if any of these items are missing, we
cannot add the wages to the employee's wage record. If you need blank copies of the Forms W-2 or W-3,
call the IRS at 1-800-829-3676. If your copies of the Forms W-2 are illegible, please prepare duplicates
on blank copies of the Forms W-2. Make sure the Forms W-2 show the correct year for the wages you
report.
Note: If you send 250 or more wage items to us, you must file your wage reports electronically in
accordance with Publication 42-007: Specifications for Filing Forms W-2 Electronically (EFW2). For
more information, please go to our website at www.socialsecurity.gov/employer or call SSA's Employer

Reporting Branch at 1-800-772-6270 from 7:00 A.M. to 7:00 P.M., Eastern time, Monday through Friday.
Monday through Friday, 7:00 a.m. to 7 p.m., Eastern Time.

999999999-99-MMDDYY

SSA-95-SM (04-11)

RETURN THIS QUESTIONNAIRE
Please send all requested information to:
Social Security Administration, Metro West
P.O. Box 33021
Baltimore, Maryland 21290-3021
Important: Do not send cash, checks, or money orders to SSA. Tax payments are payable to the
Internal Revenue Service. Send your tax payments directly to the Internal Revenue Service.

PRIVACY/PAPERWORK ACT NOTICE
Missing and Discrepant Wage Reports and Letter Questionnaire
Privacy Act Statement
Collection and Use of Personal Information
Section 205(c)(2)(A) of the Social Security Act, as amended (42 U.S.C. 405(c)(2)(A)), authorizes us to collect this
information. We will use the information you provide to help us to properly credit the earnings records for your
employees. The information you provide on this form is voluntary. However, failure to provide all or part of the
requested information will result in referral of your case to the Internal Revenue Service.
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
revised
However, we may use it for the administration andSee
integrity
of Social Security programs. We may also disclose
information to another person or to another agency
in accordance
Privacy
Act with approved routine uses, which include but are
not limited to the following:
Statement below.
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 for Social Security records (e.g., to the
Government Accountability Office, General Services Administration, National Archives Records
Administration, and the 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
agencies 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.

999999999-99-MMDDYY

SSA-95-SM (04-11)

A complete list of routine uses for this information is available in our System of Records Notices entitled Earnings
Recording and Self-Employment Income System, 60-0059. The notice, additional information regarding this form,
and information regarding our system and programs, 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 30 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.

999999999-99-MMDDYY

SSA-95-SM (04-11)

Privacy Act Statement
Collection and Use of Personal Information
Section 205(c)(2)(A) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to properly credit the employee’s earnings
record.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may result in the referral of your case to the Internal Revenue Service.
We rarely use the information you supply us for any purpose other than to reconcile
discrepancies from IRS and SSA employer-reported wages. However, we may use the
information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0059, entitled, Earnings Recording
and Self-Employment Income System. Additional information about this and other system of
records notices and our programs is available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.