Form SSA-L4002 Request for Employer Information

4002-07
Form Approved
OMB No. 0960-0508

Social Securi

Administration

5
Request for Employer Information

Retirement, urvivors, and Disability Insurance
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 u s 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
lncomplete 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 just* 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 informaci6n incorrecta sobre el nombre
o ndmero de Seguro Social del empleado. El hecho de que usted haya recibido
esta carta no constituye una razbn, de por si, para que usted tome alguna acci6n
adversa contra el empleado, tal como suspenderlo, despedirlo o discriminar
contra el individuo. Cualquier empleador que use la informaci6n en esta carta
para justincar una acci6n adversa contra un empleado puede encontrarse en
violaci6n de la ley estatal o federal, y estar sujeto a enfrentar consecuencias
legales. AdemPs, esta carta no hace ninguna declaraci6n sobre el estado de
inmigraci6n de su empleado.
Esta carta pide informaci6n sobre las ganancias que usted inform6 por su
ndmero de teli5fono gratis, 1-800-772-1213,de 7 a.m. a 7 p.m. de lunes a viemes.
Please See Reverse
4002-07

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 a s
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.)

-

REOUEST FOR EMPLOYER INFORMATION (Please Print-- Use Black Ink or #2 Pencil)
1. Name shown on the employee's Social Security card:

IIoIIIIIIIIIIIIIIIIIIIIl
M.!.

FIRST

LAST

2. Social Security number on t h e employee's card:
3. Do the earnings reported belong to this employee?

n

4. Has the employee ever used another name?

U

m-m-mn
0

0

Yes

No

n

No (Explain)

Yes (Give other names used)

Y

1101111111111111111Illll
M.!.

FIRST

LAST

5. Does the employee still work for you?

Yes

No

(Give full lest h o w1 address)

1111111lll111111
ADDRESS

cm

STATE

6. Daytime phone number where you can be reached - - -

ZIP

-

-- - -

----

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.

Enclosure:
Envelope

Carolyn L. Simmons
Associate Commissioner for
Central Operations
See Next Page
4002-07

DO NOT RETURN THIS PAGE
POINTERS FOR CORRECT REPORTING
1) The lnternal Revenue code requires a n employer to include each employee's Social Security
number when filing returns, such as the W-2 Wage and Tax Statements. The employer
identification number must also appear on such returns.
2) Ask for the employee's Social Security number and explain that the law requires the
employee to give the number although @)hemay be ineligible for benefits.
3) Include the middle initial if shown on the employee's Social Security card.
Format: John C. Smith.

THE PRIVACY ACT
Section 205(a) of the Social Security Act allows u s to ask for the information on this letter.
The information you give us will be used to give the employee credit for the correct amount of
wages. You do not have to complete this letter. However, if you do not, we cannot give the
employee credit for the correct amount of wages. We may give this information to the lnternal
Revenue Service for tax administration purposes or to the Department of Justice for
investigating and prosecuting violations of the Social Security Act.
We may also use the information you give u s when we match records by computer. Matching
programs compare our records with those of other Federal, State or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits
paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security offices. If you want to learn more about this, contact
any Social Security office.

PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the clearance requirements of 44 U.S.C. section 3507, as
amended by section 2 of the Paperwork Reduction Act o f 1995. You are not required to
answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take you about 10 minutes to read the instructions, gather
the necessary facts, and answer the questions.