Form SSA-7011-F4 Statement of Employer

Form SSA-7011-F4 (01-2019) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 4
OMB No. 0960-0030

Refer to:

DATE
PERSON TO CONTACT
TELEPHONE NUMBER
RETURN ADDRESS (SSA OFFICE)

SOCIAL SECURITY NUMBER

NAME OF WORKER

ADDITIONAL IDENTIFYING INFORMATION (To be completed by Social Security Administration when applicable)

INSTRUCTIONS ON COMPLETION OF FORM SSA-7011-F4
Please type the requested information or write legibly in ink.
If records from which you could obtain this information are not available, please explain in item 8.
Item 1: (a) Please show the value of all remuneration subject to Social Security tax exclusive of tips before any withholdings
whether paid in cash or in kind. This includes cash wages paid to domestic employees for services performed in a private
home or for work not in the course of employer's trade or business. If no wages were paid in the period(s), write "None"; if
you know that at least a certain amount was paid but you do not know the exact amount, write "Not less than $
"
and show the amount.
Item 2: (b) GOVERNMENT EMPLOYERS ONLY - Please check the proper box showing types of wages.
Please enter the amount of tips included in written reports to you b the employee during the year, whether or not the
employee Social Security tax was withheld. CAUTION - Tip amount(s) shown should not be included in the amount(s)
shown in item 1.
Item 5: If more than one year is involved, please list the information in item 8.
Item 6: Instructions on completion of item 1 apply also to this item.
Item 7: Instructions on completion of item 2 apply also to this item.
Enclosures

Form SSA-7011-F4 (01-2019) UF

Page 2 of 4

STATEMENT OF EMPLOYER
NAME OF WORKER

SOCIAL SECURITY NUMBER

1. (a) Social Security (FICA) Wages Paid
Year

Amount

Year

Amount

$

$

$

$

Wages paid before 1978, State and local
wages paid before 1981, and wages for
domestic employment
Please see item 6

(b) GOVERNMENT EMPLOYERS ONLY
Regular Social Security Wages

Medicare Qualified Government Employment

2. Cash Tips Reported
Year

Amount

Year

Amount

$

$

$

$

Cash tips reported before 1978
Please see item 7

3. Did you file employment tax return forms 941 or 942 with the Internal Revenue Service for
each period shown in items 1 and 2 above?

Yes

No

If "Yes," please go to item 4. If "No," please identify the period(s) for which you did not file a tax return, and explain why you
did not.

4. Did you submit wage report Forms W-2 and W-3, or equivalent electronic reports, to the
Social Security Administration for each period shown in items 1 and 2 above?

Yes

No

If "Yes," please go to item 5. If "No," please identify the period(s) for which you did not file a wage report, and explain why you
did not. Also, omit items 5-7.

5. For report(s) which you did file with the Social Security Administration, were the wages
and/or tip amounts listed on this form the same as shown on your report?

Yes

No

(a) If "Yes," please provide the following information and omit items 6 and 7.
DATE FILED

EMPLOYER NAME SHOWN ON REPORT

EIN SHOWN ON REPORT

(b) If "No," please show the amount of wages and/or tips reports, and explain why these amounts differ from the amounts
shown in item 1 and/or 2 of this form.

If no wages and/or tips were reported, please show "None" and explain why they were not reported. Also omit items 6 and 7.

Form SSA-7011-F4 (01-2019) UF

Page 3 of 4

6. Social Security (FICA) Wages Before 1978, State and Local wages Before 1981, and Wages for Domestic Employment.
Period

Year 19

Year 19

January 1 - March 31, inclusive

$

$

April 1 - June 30, inclusive

$

$

July 1 - September 30, inclusive

$

$

October 1 - December 31, inclusive

$

$

7. Cash Tips Reported Before 1978
Period

Year 19

Year 19

January 1 - March 31, inclusive

$

$

April 1 - June 30, inclusive

$

$

July 1 - September 30, inclusive

$

$

October 1 - December 31, inclusive

$

$

8. Remarks (Please use this space and/or plain sheets of paper for additional explanation.)

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. I understand that anyone who knowingly gives a false statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or
imprisonment.
9. EMPLOYEE'S OCCUPATION (file clerk, traveling or city
salesperson, maid, plumber, attorney, etc.)

14. NATURE OF BUSINESS (radio manufacturing, wholesale
drugs, retail grocery store, physician's office, private home,
etc.)

10. BUSINESS NAME OF EMPLOYER

15. WRITTEN SIGNATURE OF EMPLOYER OR
AUTHORIZED EMPLOYEE OF FIRM

11. EMPLOYER'S FEDERAL IDENTIFICATION NUMBER

16. PRINTED NAME AND TITLE OF PERSON SIGNING
ABOVE

12. STREET ADDRESS OF EMPLOYER

17. TELEPHONE NO. OF
INDIVIDUAL COMPLETING
FORM

13. CITY

STATE ZIP CODE

18. DATE THIS
STATEMENT FILLED
OUT

Form SSA-7011-F4 (01-2019) UF

See Revised Privacy &
PRA Statements Attached

Page 4 of 4

Privacy Act Statement
Collection and Use of Personal Information from Third Parties
Section 205 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent us from verifying wage allegations made by wage
earners.
We will use the information to process claims for Social Security benefits and to resolve discrepancies in the individual's Social
Security earnings record. We may also share this information for the following purposes, called routine uses:
•

To employers or former employers, including State Social Security administrators, for correcting and reconstructing State
employee earnings records and for Social Security purposes; and

•

To the Department of State for administering the Social Security Act in foreign countries through services and facilities of
that agency.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0059, entitled the Earnings
Recording and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819.
Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 (OMB)
control number. We estimate that it will take about 20 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.