Form SSA-L4112 Employer Verification of Earnings After Death

4112-11
RETURN THE ORIGINAL - NOT A COPY

Form Approved
OMB No. 0960-0472

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Employer Information

Social Security Administration
Data Operations Center
P.O. Box 80
Wilkes Barre, PA 18767-0080
Date:
Sequence Number:
Employer Number:
We are writing to you about your Form W-2, Wage and Tax Statement, for the
employee shown below. The amount you reported appears to be payments made
after the employee stopped working for you and is not covered by Social Security.
Employee's Name:
Social Security Number:
Reported Earnings:
Tax Year:
Please fill in the information on the back of this form and mail it to us in the
enclosed envelope. If possible, verify the number on the employee's Social Security
card and check your records to give us the information requested.
If you have any questions about this letter, you may call us toll free at 1-800-772-6270
from 7:00 a.m. to 7:00 p.m., Eastern Time. If you are deaf or hard of hearing, you
may call our TTY number, 1-800-325-0778.

Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit http://oig.ssa.gov/r or call the Inspector General's
Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

Enclosure:
Envelope

(Please See Reverse)

Form SSA-L4112 (10-2011)

4112-11
RETURN THE ORIGINAL - NOT A COPY

Page 2

Social Security Request for Employment Information
1.

Does the employee still work for you?

Yes

2.

Did employment end because the employee died?

No

(Give Last Known Address)

Yes

No

If employment ended because the employee died, refund the employee's share of the
Social Security taxes to the employee's estate or next of kin, and obtain a receipt.
Then, ask for a refund of the employer and employee Social Security taxes from the
Internal Revenue Service (IRS). For details about how to obtain a refund, contact
the IRS (there are time limits for seeking a refund from the IRS).
3.

If the earnings shown above are earnings covered by Social Security, print the name
and number shown on the employee's Social Security card and the tax year of these
earnings:
FIRST

M. INITIAL

LAST

Name:

Social Security Number:

Tax Year:

Privacy Act Statement

See
Collection and Use of Personal Information

Revised
Privacy
Act
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information.
We use the
information you provide on this form to give the employee credit for the correct
amount of
wages.
Statement
and
Completion of this form is voluntary. However, failure to provide all or part PRA
of the information could prevent
us from giving the employee credit for the correct amount of wages.

We rarely use this information you supply for any purpose other than for determining continuing eligibility.
However, we may use it for the administration and integrity of the Social Security programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses,
which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to
the Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from
these matching programs can be used to establish or verify a person's eligibility for Federally-funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems is
available on-line at www.socialsecurity.gov or at your local Social Security office.

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 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 relating to our time estimate to this address, not the completed form.

Form SSA-L4112 (10-2011)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 205(c)(2)(A) of the Social Security Act, as amended, allows us to collect this information.
We will use the information you provide to give the employee credit for the correct amount of
wages.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from giving the employee credit for the correct amount of wages.
We rarely use the information you supply for any purpose other than what we state above,
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);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices, 60-0059, entitled Earnings Recording and SelfEmployment Income System. Additional information about these and other system of records
notices and our programs is available from our Internet website at www.socialsecurity.gov or at
your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used 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 as soon
as possible:
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 21235-6401.