Form SSA-L2765 Request for Self-Employment Information

2765-06

Form Approbed

OMR No. W60-0508

Social Securi

Administration

5
Request for Self-Employment Information

Retirement, urvivors, and Disability Insurance
Social Security Administration
IYala Operntions Cenler
P.O. Box 39
Wilkes-Barre, PA 18767-1745
Date:
Sequence Number:
Employer Number:
We need more information about self employment earnings reported to u s by the
Internal Revenue Service. Please complete the information on the back of this letter and
rehlrn it to us promptly. We cannot put these earnings on your Social Security record
~ ~ r l rthe
i l name and Social Security number reported agree with our records.

Hame:
Bwlal &curlty lumbar:
Reported Met Enrnkngm from Sslf-Employment:
Tax Year:

THIS IS WHAT YOU NEED TO W
1. If your Social Srcurity card does not show your correcl name or Social Security

rurmber, or ilyou have lost your Social Security card, please call our toll-free nnmtlrr..
1-800-772~
1213. or contact your local Social Security office.

2 , Compare the information shown above to the Schedule SE of your tax return and
your Social Security card.
3. If the name and number shown on the Social Security card:
- Do not agree a i t h the information shown above. fill in the requested information
on the back of this letter. Then mail this letter to us in the enclosed envelope.
- Agree esnctly with the information shown above, contact your local Social
Security offxce. Do not mail this letter back to us.
4

Make sirre char your future tax returns have your correct name and Soc~alSecurity

number

Xi

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Please Scc Kevcrse

REQlJEST FOR SELF-EMPLOYMENT INFORMATION
1 . Name s h o w on your Soc~alSecurity card

(Rraw Pnnr--Usc Blnck Ink or rt2 &nrtlJ

I l I l l l l l l l l l l l I IU I I I I I I I I I I I I I I I I I I I I I
M.1.

F~rar

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2. Social Srcuri~ynumber on your card:

3. Were the earnings s h o ~ mon the front of this letter reported on your Uoint/individuall tax
return:'

...-....--.-.......

.-

.............

.

a

If Yes, do the earnings reported belong to:

....

Your spouse (Plerse check one)

You

Spouse's Name:
Spuuue's SSN:
4

Have you rver usrd another name?

0

No

a

Yes (OI\.~
other n;lrnes

UHP~)

Illill
Firnt

M.I.

Last

I I I I I I I I I[71111111111111111111ll
First

M.I.

3. Daytiinc: phone number where you can be reached

Lasl

.-

--

-

-

-

- - - --

If you h a arly
~ queshons, you may call u s toll-free at 1-800-772- 12 13 We can answer
most questions over the phone. You can also write or visit m y Soclal Security office. If
you do call or visit an office, please have this letter with you. The office that serves
your area is located at:

Carolyn I.. S~mmons
Associate Commissioner fbr
Central Operations
Enclosure:
Envelope
See Next Page
2765-06

DO HOT RETURH THIB PAGE

THE PRIVACY ACT
Section 2051~)
of the Social Security Act allows us to ask for the information on this
letter. Thc information you give u s uill be used to give you credit for earnings reported.
You do not have to give us this information. However, without the information we may
not be able to give you credit for wages earned. We may give this in for ma ti or^ to the
Internal Revenue Service for tax administration purposes or to the Department of Justice
for investigating and prosecuting violations of the Social Security Act.

W e may alsu use the information you give US when we match records by computer.
Matching programs compare our records with those of other Federal. State or local
government wencies. Many agencies may use matching programs to fuld or prove that a
person qualifies for benefits paid by the Federal government. The law allows u s to do
this even if you do not agree LO it. Explanations about these and other reasons why
i~tbrmationyou provide us may be used or given out tue available in Social Security
offices. If you
to learn more about this, contact any Social Security ofice.

This information collection meets the clearance requirements of 44 U.S.C. section 3507,
as amctlded by section 2 of the h p e r m r k Radnctioa Act of 199s. You arc nor
required to auswer these questions unless we display n valid Ofice of Mena~cmentand
Budget control number. We estimate that it wit1 take you about 10 minutes Lo read
the ins~ructic~ns.
gather the necessary facts, and answer the questions.