Statement of Employer

OMB 0960-0030

OMB 0960-0030

SSA uses Form SSA-7011-F4 to substantiate allegations that earnings posted to the individual’s security record are incorrect, wages paid to the individual do not appear in SSA’s records of earnings, or the individual has no proof of said earnings. SSA uses the information received on this form to process claims for social security benefits and to resolve discrepancies in the individual’s social security earnings record. We only send Form SSA-7011-F4 to employers if we deem it necessary; in many situations, we are able to locate the earnings information within our records, without having to contact the employer. The respondents are certain employers who can verify wage allegations made by the wage earners.

The latest form for Statement of Employer expires 2021-10-31 and can be found here.

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Revision of a currently approved collection 2021-09-10
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Revision of a currently approved collection 2018-08-20
Approved without change
Revision of a currently approved collection 2015-09-18
Approved without change
Revision of a currently approved collection 2012-10-04
Approved without change
Revision of a currently approved collection 2009-06-12
Approved without change
Revision of a currently approved collection 2006-06-02
Approved without change
Extension without change of a currently approved collection 2003-05-27
Approved without change
Extension without change of a currently approved collection 2000-04-07
Approved without change
Extension without change of a currently approved collection 1997-03-14
Approved without change
Extension without change of a currently approved collection 1993-11-03
Approved without change
Revision of a currently approved collection 1990-05-14
Approved with change
No material or nonsubstantive change to a currently approved collection 1989-09-08
Approved without change
Revision of a currently approved collection 1987-05-22
Approved without change
Extension without change of a currently approved collection 1984-08-17
Approved without change
Reinstatement with change of a previously approved collection 1982-08-13
Approved without change
Extension without change of a currently approved collection 1981-08-26
Approved without change
Reinstatement with change of a previously approved collection 1981-07-29
Approved without change
Revision of a currently approved collection 1980-08-05
Approved with change
No material or nonsubstantive change to a currently approved collection 1979-03-29
Approved without change
Extension without change of a currently approved collection 1977-11-04
Approved without change
Reinstatement with change of a previously approved collection 1977-10-28

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