OMB control number
Statement of Employer
OMB 0960-0030 · SSA.
OMB 0960-0030
When workers report they were paid wages, but cannot provide proof of those earnings, and the wages do not appear in SSA’s records of earnings, SSA uses Form SSA-7011-F4 to document the alleged wages. Specifically, the agency uses the form to resolve discrepancies in the individual’s Social Security earnings record, and to process claims for Social Security benefits. We only send Form SSA-7011-F4 to employers if we are unable able to locate the earnings information within our own records. The respondents are employers who can verify wage allegations made by wage earners.
The latest form for Statement of Employer expires 2028-07-31 and is listed under ICR 202505-0960-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form SSA-7011-F4 Statement of Employer | Form |
| Form SSA-7011-F4 Statement of Employer | Form |
| PC_202505-0960-001_071725_120722_1.pdf | Public Comments |
 Supporting Statement 0960-0030 (final).docx | Supporting Statement A |
| Supporting Statement 0960-0030 (final).docx | Supporting Statement A |
 Statement of Employer |
Form |
| Statement of Employer |
Form |