Form SSA-L4002 Request for Employer Information

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Form Approved
OMB No. 0960-0508

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

Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes-Barre, PA 18767-0039
Date:
Sequence Number:
Employer Number:
We are writing to you about your Wage and Tax Statement (W-2) or Corrected
Wage and Tax Statement (W-2c) for the employee shown below. Please complete the
information on the back of this letter and return it to us promptly. We cannot put
these earnings on the employee's Social Security record until the name and Social
Security number you reported agree with our records.
Employee's Name:
Social Security Number:
Reported Earnings:
Tax Year:
The reasons the reported information does not agree with our records may include,
but are not limited to:
Typographical errors
Incomplete or blank name reported
Incomplete or blank Social Security number (SSN) reported
Name changes
This letter does not imply that you or your employee intentionally provided
incorrect information about the employee's name or SSN. It is not a basis, in and
of itself, for you to take any adverse action against the employee, such as laying off,
suspending, firing, or discriminating against the individual. Any employer that uses
the information in this letter to justify taking adverse action against an employee
may violate state or Federal law and be subject to legal consequences. Moreover,
this letter makes no statement about your employee's immigration status.
For Spanish-speaking individuals: Esta carta no implica que usted ni su empleado
intencionalmente proveyeron información incorrecta sobre el nombre o número de
Seguro Social del empleado. El hecho de que haya recibido esta carta no
constituye una razón, de por sí, para que tome alguna acción adversa contra
el empleado, tal como suspenderlo, despedirlo o discriminar contra el individuo.
Cualquier empleador que use la información en esta carta para justificar una
acción adversa contra un empleado puede encontrarse en violación de la ley
estatal o federal, y estar sujeto a enfrentar consecuencias legales. Además, esta
carta no hace ninguna declaración sobre el estado inmigratorio de su empleado.
Esta carta pide información sobre las ganancias que usted informó para su
empleado. 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-L4002-C1 (01/2011)

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THIS IS WHAT YOU NEED TO DO
1. Compare the information shown on the front of this letter to your employment records.
2. If the records match, ask the employee to give you the name and Social Security
number exactly as it appears on the employee's Social Security card. (While the
employee must furnish the SSN to you, the employee is not required to show you the
Social Security card. But, seeing the card will help ensure that all records are correct.)
3. If the employee's Social Security card does not show the employee's correct name or
Social Security number, or if the employee needs to report a name change or replace a
lost Social Security card, have the employee contact any Social Security office.
4. If you or the employee has been using an incorrect name or Social Security number,
you must correct it.
5. Fill in the requested information below and return this letter in the enclosed envelope.
(Do not attach a Form W-2c to this letter.)

REQUEST FOR EMPLOYER INFORMATION (Please Print-1. Name shown on the employee's Social Security card:
First

M.I.

Last

2.

Social Security number on the employee's card:

3.

Do the earnings reported belong to this employee?

4.

Has the employee ever used another name?

First

5.

Use Black Ink or #2 Pencil)

Yes

No

No

Yes

(Explain)

(Give other names used)

Last

M.I.

Does the employee still work for you?

Yes

No

(Give full last known address)

ADDRESS

STATE

CITY

6.

ZIP

Daytime phone number where you can be reached

If you have any questions, you may call us toll-free at 1-800-772-6270 from 7 a.m. to 7 p.m.,
Monday through Friday, Eastern time. If you call an office, please have this letter with
you. It will help us to answer your questions.

Enclosure:
Envelope

See Next Page

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DO NOT RETURN THIS PAGE
POINTERS FOR CORRECT REPORTING
1) The Internal Revenue Code requires an employer to include each employee's
Social Security number when filing returns, such as the W-2 Wage and Tax
Statements. The employer identification number must also appear on such
returns.
2) Ask for the employee's Social Security number and explain that the law
requires the employee to give the number although (s)he may be ineligible
for benefits.
3) Include the middle initial if shown on the employee's Social Security card.
Format: John C. Smith

THE PRIVACY ACT

See Revised Privacy Act
Statement

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 the employee
credit for the correct amount of wages. You do not have to complete this letter.
However, if you do not, we cannot give the employee credit for the correct
amount of wages. 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.

Revised PRA Statement
PAPERWORK REDUCTION ACTSee
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.

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, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from crediting the employee the correct amount of wages
earned.
We will use the information you provide to give the employee credit for the correct amount of
wages earned. We may also share this information for the following purposes, called routine
uses:
1. To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of our programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared to other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice, 600059, entitled Earnings Recordings and Self-Employment Income System. Additional
information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

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.