Form SSA-4156 Employee Identification Statement

Form SSA-4156 (03-2017)
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0473
See Paperwork Reduction Act /
Privacy Act Notice on Reverse

Employee Identification Statement
1. Is the Social Security number on the letter the same as on your records?

Yes

No

If "No," what do your records show?

2. Full Name of Employee

3. a. Date of Birth

b. Place of Birth

4. Last Known Address of Employee

5. a. Physical Description (please provide a copy of photo ID if available)

b. Distinguishing Characteristics

From

6. Dates of Employment With Your Company

To

7. Business Name of Employer

8. Employer's Federal Identification Number

9. a. Street Address of Employer

b. City

c. State

d. ZIP Code

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a
false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
subject to a fine or imprisonment.
10. For signature comparison, please send a photocopy of the individual's form W-4, if available.
Signature (First name, middle initial, last name)(Write in ink)

Date (month, day, year)

Telephone Number

Print name

Title

Form SSA-4156 (03-2017)

Page 2 of 2
Privacy Act Statement

Title 20 CFR 404.702 of the Social Security Act, as amended, authorizes us to collect this information. We will use the
information you provide to assure that a person’s wage record is accurate and make a correct determination of eligibility for
Social Security benefits.

See Revised Privacy Act Statement Attached

The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent us
from assuring that a person’s wage record is accurate and prevent us from making a correct determination of eligibility for
Social Security benefits.
We rarely use the information you supply for any purpose other than for making a determination about your continuing
eligibility benefits. However, we may use it for the administration and integrity of 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 assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
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.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled, Earnings
Recording and Self-Employment Income System, 60-0059 and Master Beneficiary Record, 60-0090. These notices,
additional information regarding this form, and information regarding our programs and systems, are 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 5 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.