Information Collection

Employer Verification of Earnings After Death

IC 9361 under ICR 202610-0960-001 · OMB 0960-0472.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L4112 Employer Verification of Earnings After Death Employer Verification of Earnings After Death	Form
Privacy Act Staement-Revised.docx	Other-0960-0472 Revised Privacy Act
SSA-L4112 Employer Verification of Earnings After Death SSA-4112-Revised.pdf	Form
SSA-L4112 -current.pdf Current SSA-L4112	IC Document

IC Title:

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 404.821 20 CFR 404.822

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				No		Paper Only
Other-0960-0472 Revised Privacy Act Statement					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27,304

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,304	14,190	13,114
Annual IC Time Burden (Hours)	18,203	13,832	4,371
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-L4112		10/28/2026

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

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