Form SSA-L2765 Request for Self-Employment Information

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Form Approved
OMB No. 0960-0508

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Self-Employment Information

Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes-Barre, PA 18767-0039
Date:
Sequence Number:
Employer Number:
We need more information about self-employment earnings reported to us by the
Internal Revenue Service. Please complete the information on the back of this
letter and return it to us promptly. We cannot put these earnings on your Social
Security record until the name and Social Security number reported agree with our
records.
Name:
Social Security Number:
Reported Net Earnings from Self-Employment:
Tax Year:
THIS IS WHAT YOU NEED TO DO
1. If your Social Security card does not show your correct name or Social Security
number, or if you have lost your Social Security card, please call our toll-free
number, 1-800-772-1213, or contact your local Social Security office.
2. Compare the information shown above to the Schedule SE of your tax return and
your Social Security card.
3. If the name and number shown on the Social Security card:
- Agree exactly with the information shown above, contact your local Social
Security office. Do not mail this letter back to us.
- Do not agree with the information shown above, fill in the requested
information on the back of this letter. Then mail this letter to us in the
enclosed envelope.
4. Make sure that your future tax returns have your correct name and Social
Security number.

Si usted necesita una traducción de esta carta, por favor llámenos gratis
al, 1-800-772-1213, de lunes a viernes, desde las 7 a.m. hasta las 7 p.m.
Please See Reverse

Form SSA-L2765-C1 (01/2011)

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REQUEST FOR SELF-EMPLOYMENT INFORMATION

1. Name shown on your Social Security card:

First

(Please Print-- Use Black Ink or #2 Pencil)

Last

M.I.

2. Social Security number on your card:
3. Were the earnings shown on the front of this letter reported on your (joint/individual) tax
return?

If No, explain

If Yes, do the earnings reported belong to:

You

Your spouse

(Please check one)

Spouse's Name:

First

Last

M.I.

Spouse's SSN:
4. Have you ever used another name?

No

Yes

(Give other names used)

First

M.I.

Last

First

M.I.

Last

5. Daytime phone number where you can be reached
If you have any questions, you may call us toll-free at 1-800-772-1213. We can answer
most questions over the phone. You can also write or visit any Social Security office.
If you do call or visit an office, please have this letter with you. The office that
serves your area is located at:

Enclosure:
Envelope
See Next Page

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See Revised Privacy Act Statement Attached
THE PRIVACY ACT
Section 205(a) of the Social Security Act allows us to ask for the information on
this letter. The information you give us will be used to give you credit for
earnings reported. You do not have to give us this information. However, without
the information we may not be able to give you credit for wages earned. We may
give this information to the Internal Revenue Service for tax administration
purposes or to the Department of Justice for investigating and prosecuting
violations of the Social Security Act.
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law
allows us to do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out are
available in Social Security offices. If you want to learn more about this, contact
any Social Security office.

PAPERWORK REDUCTION ACT STATEMENT

See Revised PRA 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 control
number. We estimate that it will take about 10 minutes to read the instructions,
gather the facts, and answer the questions. You may send comments on our time
estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments related to our time estimate to this address, not the completed
form.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(c)(2)(A) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to give you credit for earnings
reported.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from crediting your earned wages.
We rarely use the information you supply us for any purpose other than to make a determination
regarding claims and earnings discrepancies. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act Systems of Records Notice entitled, Earnings Recording and SelfEmployment Income System, 60-0059. Additional information about this and other system of
records notices and our programs are available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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
10 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 21235-0001.