Form SSA-L4201 Letter to Employer Requesting Wage Information

Page 1 of 6

Form SSA-L4201-BK (07-2018) UF
Discontinue prior editions

OMB No. 0960-0138

SOCIAL SECURITY
Important Information

Office Address:

Telephone
Number:
FAX Number:
Office Hours:
Date:
We are asking for your help in obtaining wage information about the employee named on the
attached pages. Please complete sections 1 through 3 of the form if they are indicated, and section 5
in all cases.
If you prefer to send a payroll printout instead of completing the form, please include an explanation
of the items on the printout.
For your convenience, we are enclosing a postage-paid reply envelope. If a fax number is shown
above, you may instead fax the information to that number.
We appreciate your help in this matter. If you have any questions, please call the telephone number
above and ask for
.

Enclosure(s)
Stamped Reply Envelope

Field Office Manager:

Page 2 of 6

Form SSA-L4201-BK (07-2018) UF

Privacy Act Statement
Collection and Use of Personal Information
Sections 1611(c), 1612(a), and 1631(e)(1) 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 making an accurate and timely decision on benefit eligibility or
could result in loss of benefits of the named claimant.
We will use the information to verify wages of the named Supplemental Security Income applicant or
recipient to determine eligibility and benefit amount. We may also share your information for the
following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We will
disclose information under this routine use only in situations in which SSA may enter a
contractual or similar agreement with a third party to assist in accomplishing an Agency function
relating to this system of records; and
• To third party contacts (e.g., employers and private pension plans) in situations where the party
to be contacted has, or is expected to have, information relating to the individual's capability to
manage his/her affairs or his/her eligibility for, or entitlement to, benefits under the Social
Security program when the data are needed to establish the validity of evidence or to verify the
accuracy of information presented by the individual, and it concerns one or more of the
following his/her eligibility for benefits under the Social Security program; the amount of his/her
benefit payment; or any case in which the evidence is being reviewed as a result of suspected
fraud, concern for program integrity, quality appraisal, or evaluation and measurement activities.
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 Notices (SORN)
60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on April 1,
20013, at 68 FR 15784, 60-0090, entitled Master Beneficiary Record, as published in the FR on
January 11, 2006, at 71 FR 1826, and 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional
information and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement

See Revised Privacy Act &
PRA Statements attached

This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by
Section 1 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 30 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is listed under the U.S. Government agencies in your telephone directory or you may call
Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time
estimates above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Page 3 of 6

Form SSA-L4201-BK (07-2018) UF

EMPLOYEE NAME
SOCIAL SECURITY NUMBER REFERENCE NUMBER
1. Current Wages. Please show the following:
• Is the individual named above still employed with your company?
Yes

No

(If employment terminated, show the date last paid and the date last worked in the blocks
below. It is not necessary to complete the rest of this section. If employment has NOT
terminated, skip the first two blocks below and complete the rest of this section.)
Date Last Worked (MMDDYY)

Date Last Paid (MMDDYY)

Current rate of pay (per hour, day, week, piece, etc.):

$

per

$

per

Amount worked per pay period (in hours, days, pieces, etc.):
Day of week or date(s) of month on which paid:
How often paid (weekly, biweekly, monthly, etc.):
Date last paid (month, day, year):
Rate of overtime pay (per hour, day, week, etc.):
Average overtime per pay period (no. of hours):
Please describe any changes you expect in any of the information shown above:

2. DEDUCTIONS FROM GROSS WAGES
• Does the employee participate in a CAFETERIA PLAN?
Yes

No

A cafeteria plan is a pre-tax plan undersection 125 of the Internal Revenue Code. Under a
cafeteria plan, employees can choose, cafeteria-style, from a menu of two or more qualified
benefits, or cash. Qualified benefits include, but are not limited to, accident and health
plans, group term life insurance plans, dependent care assistance plans, and certain stock
bonus plans undersection 401(k)(2) (but not 401(k)(1)) of the Internal Revenue Code.
Cafeteria plans are often shown on pay slips as FLEX, CHOICES, Sec. 125, café plan, etc.
• Are any of the employee's wages garnished for child support?
Yes

No

Page 4 of 6

Form SSA-L4201-BK (07-2018) UF

EMPLOYEE NAME

SOCIAL SECURITY NUMBER REFERENCE NUMBER

3. PRIOR WAGES. Please read the following instructions and provide the information requested
on the following page(s).
What We Need To Know About Wages and Deductions
Wages
We need to know the amount of gross wages paid to the employee in each of the months
checked on the back of this page and any additional pages. Base these amounts on actual
paydays in the month, not the ending dates of pay periods. For example, wages earned in a
pay period ending on May 29 but actually paid on June 5 would be included in the total gross
wages paid in June. If no wages were paid to the employee in a month that is checked, please
show "none."

Be sure to include in gross wages:
• Tips
• Bonuses
• Overtime
• Holiday and vacation pay
• The dollar value of payments in kind (meals or lodging, for example)
• Any contributions under a salary reduction agreement to a cafeteria plan as defined in section
125 of the Internal Revenue Code
• Garnished child support.
Do not include in gross wages any advance earned income tax credit payments.
Deductions
Please also provide the amount of any cafeteria plan deductions, garnished child support, or
any other item indicated at the top of these columns to the right of the gross wages. Please
show "none," if applicable. Completion of the "OTHER" column is only needed when a specific
item is listed at the top of that column.

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Form SSA-L4201-BK (07-2018) UF

EMPLOYEE NAME
GROSS WAGES
PAID IN MONTH

SOCIAL SECURITY NUMBER REFERENCE NUMBER

January
February
March
April
May
June
July
August

$
$
$
$
$
$
$
$

CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

September
October
November
December

$
$
$

$
$
$

$

$
$
CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$

$

YEAR:

GROSS WAGES
PAID IN MONTH

YEAR:
January
February
March
April
May
June
July
August
September
October
November
December

$
$
$
$
$
$
$
$
$
$
$

$
4. Additional Information/Comments:

$
$
$

$

5. Signature:
Title:
Employer's Name:
Telephone:

Date:

FAX:

OTHER
$
$
$
$
$
$
$
$
$
$
$
$
OTHER

Page 6 of 6

Form SSA-L4201-BK (07-2018) UF

EMPLOYEE NAME
GROSS WAGES
PAID IN MONTH

YEAR:
January
February
March
April
May
June
July
August
September
October
November
December

$
$
$
$
$
$
$
$
$
$
$
$
GROSS WAGES
PAID IN MONTH

YEAR:
January
February
March
April
May
June
July
August
September
October
November
December

$
$
$
$
$
$
$
$
$
$
$

$
4. Additional Information/Comments:

SOCIAL SECURITY NUMBER REFERENCE NUMBER
CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$
$
CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$

$

$

5. Signature:
Title:
Employer's Name:
Telephone:

OTHER

Date:

FAX:

$
OTHER