Form SSA-L4112 Employer Verification of Earnings After Death

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Form Approved
OMB No. 0960-0472

Social Security Administration

Retirement, Survivors, and Disability Insurance
Request for Employer Information

Social Security Administration
Wilkes-Barre Direct 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.

Social Security, GdminwUatiaii
Enclosure:
Envelope

(Please See Reverse)

Form SSA-L4112 (01-2020)

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Page 2

Social Security Request for Employment Information

1.

Does the employee still work for you?

EH Yes

2.

Did employment end because the employee died?

EH No

(Give Last Known Address)

EH Yes

I I 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

LAS!

Name:

Social

Security

Number:

—

—

Tax Year:

Privacy Act Statement

Collection and Use of Personal Information
Section 205(c), 209(a), and 232 of the Social Security Act, as a mended, allows us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information could prevent us from giving the employee credit for the correct amount of
wages.

We will use the information you provide to verify wage information previously received and
properly credit the employee for the correct amount of wages earned. We may also share your
information for the following purposes, called routine uses:
•

To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes; and

•

To officers and employees of Federal, State or local agencies upon written request in
accordance with the Internal Revenue Code (IRC) U.S.C. 6103(l)(7)), tax return
information (e.g., information with respect to net earnings from self-employment, wages,
payments of retirement income which have been disclosed to the Social Security
Administration, and business and employment addresses) for purposes of, and to the
extent necessary in, determining an individual's eligibility for, or the correct amount of,
benefits under certain programs listed in the IRC.

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 with 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
(SORN) 60-0059, entitled Earnings Records and Self-Employment Income System, as published
in the Federal Register (FR) on January 11, 2006, at 71 FR 1819. Additional information, and a
full listing of all of our SORNs, is available on our website at https://www.ssa.gov/privacy.

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 20 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.
Form SSA-L4112 (01-2020)