Employer Verification of Earnings After Death

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0472 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-L4112 Employer Verification of Earnings After Death Form
SSA-L4112 Employer Verification of Earnings After Death SSA-L4112 - Revised Version.pdf Form
SSA-L4112 - Current Version.pdf Current SSA-L4112 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employer Verification of Earnings After Death	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.822 20 CFR 404.821

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4112	Employer Verification of Earnings After Death	SSA-L4112 - Revised Version.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54,998	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	54,998	4,998	50,000
Annual IC Time Burden (Hours)	9,166	833	8,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L4112	SSA-L4112 - Current Version.pdf	05/24/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.