Form SSA-L4002 Request for Employer Information

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Form Approved

OMB No- 0960-0508

Socml 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 informacion incorrecta sobre el nombre o numero de
Seguro Social del empleado. El hecho de que haya recibido esta carta no
constituye una razon, de por si, para que tome alguna accion adversa contra
el empleado, tal como suspenderlo, despedirlo o discriminar contra el individuo.
Cualquier empleador que use la informacion en esta carta para justificar una

accion adversa contra un empleado puede encontrarse en violacion de la ley
estatal o federal, y estar sujeto a enfrentar consecuencias legales. Ademas, esta
carta no hace ninguna declaracion sobre el estado inmigratorio de su empleado.
Esta carta pide informacion sobre las ganancias que usted informo para su
empleado. Si usted necesita una traduccion de esta carta, por favor llamenos
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-M002-C]

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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:

II

First

M.I.

Socia 1 Security number on thes employee

3.

Do the earnings reported belong to this employee?

4.

Has the employee ever used another• name?

5.

or

#2 Pencil)

Last

2.

First

Use Black Ink

s

card

—

Yes

No

M.I.

—

Yes

No

(Explain)

(Give other names used)

Last

Does the employee still work for you?

Yes

No (Give full last known address)

ADDRESS

CITY

6.

STATE

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.

Social Security ttdnunhtxatuui
Enclosure:
Envelope

See Next Page

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PRIVACY ACT STATEMENT

Collection and Use of Personal Information

Sections 2O5(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.socialsecuritv.gov/foia/bluebook.

See Revised Privacy Act & PRA
Statements attached

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.

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
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 proper earnings record.
We will use the information you provide to ensure wages and self-employment income are
properly identified and credited to the appropriate earnings record. We may also share the
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 contractors or other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its 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 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 Recording 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
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 10 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.