Current SSA-L4112

Form SSA-L4112 (05-2019)
Discontinue Prior Editions
Social Security Administration

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OMB. No. 0960-0472

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Employer Information

Social Security Administration
Data 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 7:00am to 7:00pm,
Eastern Standard Time. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778.

Social Security Administration

Enclosure:
Envelope

(Please See Reverse)

Form SSA-L4112 (05-2019)

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Social Security Request for Employment Information
1. Does the employee still work for you?

Yes

No

2. Did employment end because the employee died?

Yes

No

(Give Last Known Address)

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

LAST

NAME
Tax Year:

Social Security Number:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(c), 209(a), and 232 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 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(1)(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 control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.