Employer Verification of Earnings After Death

Documents and Forms

Document Name Document Type
Form SSA-L4112 Employer Verification of Earnings After Death Form
0960-0472 Privacy Act Statement (revised).docx Other-0960-0472 Revised Privacy Act
SSA-L4112 Employer Verification of Earnings After Death SSA-L4112 (revised).pdf Form
SSA-L4112 (current).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).pdf		No		Paper Only
Other-0960-0472 Revised Privacy Act Statement			0960-0472 Privacy Act Statement (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,114	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,114	-41,884	54,998
Annual IC Time Burden (Hours)	4,371	-4,795	9,166
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L4112	SSA-L4112 (current).pdf	07/07/2022

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