Information Collection

Employer Verification of Earnings After Death

IC 9361 under ICR 201911-0960-008 · OMB 0960-0472.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0472 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L4112 Employer Verification of Earnings After Death	Form
SSA-L4112 Employer Verification of Earnings After Death SSA-L4112 (revised).pdf	Form
SSA-L4112 (current).pdf Current SSA-L4112	IC Document

IC Title:

Employer Verification of Earnings After Death

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.822 20 CFR 404.821

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4112	Employer Verification of Earnings After Death	SSA-L4112 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54,998

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	54,998	54,998
Annual IC Time Burden (Hours)	9,166	9,166
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-L4112	SSA-L4112 (current).pdf	11/25/2019

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