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Employer Requesting Report
ICR 202602-0960-006 · OMB 0960-0034 · Object 166619200.
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Document Metadata
| File Type | application/pdf |
|---|---|
| File Title | Employer Requesting Report |
| Subject | Employer Requesting Report, SSA-L725 |
| Keywords | SSA-L725, Employer Requesting Report, 725, L725 |
| Author | SSA |
| Last Modified By | Designer 6.2 |
| File Modified | 2023-08-02 |
| File Created | 2023-07-28 |
| Conversion State | complete |
Extracted Text
Form SSA-L725 (07-2023) UF Discontinue Prior Editions Social Security Administration Page 1 of 3 OMB No. 0960-0034 SOCIAL SECURITY Date: Refer to: Social Security Number: Worker's Name: • Area Code: Telephone: So that we may determine the above-named person's eligibility for Social Security benefits, please furnish the amount of gross wages earned by the employee in each of the months checked below. If no wages were earned in a month, show "none." Please note that we need to know the amounts earned for services performed within the calendar month, regardless of the amounts paid. If the employee received cash tips, include the amount in the totals for the month. We appreciate your cooperation in furnishing this information. An envelope requiring no postage is enclosed for your convenience. A computerized printout in any format may be substituted for the enclosed form. Sincerely Yours, Enclosure Ending Date of Employment: Beginning Date of Employment: If the amount of wages for each month is the same, enter the monthly amount here. Year: January $ April $ July $ October February May August November March June September December See other side for additional years (check if applicable). $ Page 2 of 3 Form SSA-L725 (07-2023) UF If the amount of wages for each month is the same, enter the monthly amount here. Year: January $ April $ July $ October February May August November March June September December If the amount of wages for each month is the same, enter the monthly amount here. Year: January $ April $ July $ October February May August November March June September December $ April July $ $ October February May August November March June September December $ If the amount of wages for each month is the same, enter the monthly amount here. Year: January $ If the amount of wages for each month is the same, enter the monthly amount here. Year: January $ $ April $ July $ October February May August November March June September December $ 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. EMPLOYER NAME AREA CODE AND TELEPHONE NO. TITLE DATE Page 3 of 3 Form SSA-L725 (07-2023) UF Privacy Act Statement Collection and Use of Personal information Sections 205(a) and 223(d) of the Social Security Act, as amended, allow 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 making an accurate and timely decision on any claim filed or could result in the loss of benefits. We will use the information you provide to verify wages, resolve wage discrepancies, and determine benefit eligibility. We may also share the 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 contractors and other Federal Agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs. We will disclose information under this routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an Agency function relating to this system of records. 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 Notices (SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819, 60-0089, entitled Claims Folders System, as published in the FR on October 31, 2019, at 84 FR 58422, and 60-0330, entitled eWork, as published in the FR on September 15, 2003, at 68 FR 54037. 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 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 40 minutes to read the instructions, gather the facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.