Information Collection

Letter to Employer Requesting Wage Information

IC 9117 under ICR 201710-0960-004 · OMB 0960-0138.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0138 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-L4201 Letter to Employer Requesting Wage Information Form
Revised PA Statement.pdf Other-Revised PA Statement
SSI Wage Screens.docx Other-SSI Wage Screens
SSA-L4201 Letter to Employer Requesting Wage Information SSA-L4201 - Revised.pdf Form
SSA-L4201 - Current.pdf SSA-L4201 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Letter to Employer Requesting Wage Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-L4201	Letter to Employer Requesting Wage Information	SSA-L4201 - Revised.pdf	No	Fillable Printable
Other-Revised PA Statement			Revised PA Statement.pdf	No	Fillable Printable
Other-SSI Wage Screens			SSI Wage Screens.docx	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 133,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	133,000	133,000
Annual IC Time Burden (Hours)	66,500	66,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-L4201 - Current	SSA-L4201 - Current.pdf	11/20/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.