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pdfForm Approved
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
.
Field Office Manager
Enclosure(s)
Stamped Reply Envelope
Form SSA-L4201 BK (01-2008) EF (01-2008)
PAPERWORK/PRIVACY ACT NOTICE
See revised
Privacy Act
Statement below.
Section 1611(c), 1612(a)(1), and 1631(e)(1) of the Social Security Act allow us to ask for wage
information about the worker named on the attached form. Your response to this request is voluntary.
However, failure to respond to this request may have an adverse effect upon the worker or other
individual involved. We will use the information you provide to resolve a Social Security matter
involving this worker.
We may routinely disclose this information without your consent or the individual's consent if:
1. A Federal law requires that we give out this information;
2. A Member of Congress or the President's office needs this information to answer questions asked by
the individual;
3. A government agency needs this information to administer an income maintenance or health
maintenance program;
4. Someone needs this information to do statistical research or audit report for us related to the
Social Security programs;
5. The Department of Justice needs the information to represent the Federal Government in a court suit
related to a Social Security Administration matter.
We may also 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 agencies. Many agencies
may use matching programs to find or prove that a person qualified 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 others 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. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 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 30 minutes to read the instructions, gather the necessary facts, and answer the questions.
SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is listed under 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 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.
Form SSA-L4201 BK (01-2008) EF (01-2008)
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.):
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):
$
per
$
per
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 under section 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
under section 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, cafe plan, etc.
• Are any of the employee's wages garnished for child support?
YES
NO
Form SSA-L4201 BK (01-2008) EF (01-2008)
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.
Form SSA-L4201 BK (01-2008) EF (01-2008)
EMPLOYEE NAME
YEAR
___________
__ January
January
__ February
February
__ March
March
__ April
April
__ May
May
__ June
June
__ July
July
__ August
August
__ September
September
__ October
October
__ November
November
__ December
December
GROSS WAGES
PAID IN MONTH
__ February
February
__ March
March
__ April
April
__ May
May
__ June
June
__ July
July
__ August
August
__ September
September
__ October
October
__ November
November
__ December
December
CAFETERIA PLAN
DEDUCTIONS
REFERENCE NUMBER
CHILD SUPPORT
GARNISHMENTS
OTHER
$
$
$
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YEAR
___________
__ January
January
SOCIAL SECURITY NUMBER
GROSS WAGES
PAID IN MONTH
CAFETERIA PLAN
DEDUCTIONS
CHILD SUPPORT
GARNISHMENTS
OTHER
$
$
$
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4. ADDITIONAL INFORMATION/COMMENTS:
5. Signature
Date:
Title:
Employer
Telephone:
FAX:
Form SSA-L4201 BK (01-2008) EF (01-2008)
EMPLOYEE NAME
YEAR
___________
__ January
January
__ February
February
__ March
March
__ April
April
__ May
May
__ June
June
__ July
July
__ August
August
__ September
September
__ October
October
__ November
November
__ December
December
GROSS WAGES
PAID IN MONTH
__ February
February
__ March
March
__ April
April
__ May
May
__ June
June
__ July
July
__ August
August
__ September
September
__ October
October
__ November
November
__ December
December
CAFETERIA PLAN
DEDUCTIONS
REFERENCE NUMBER
CHILD SUPPORT
GARNISHMENTS
OTHER
$
$
$
$
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YEAR
___________
__ January
January
SOCIAL SECURITY NUMBER
GROSS WAGES
PAID IN MONTH
CAFETERIA PLAN
DEDUCTIONS
CHILD SUPPORT
GARNISHMENTS
OTHER
$
$
$
$
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4. ADDITIONAL INFORMATION/COMMENTS:
5. Signature
Date:
Title:
Employer
Telephone:
FAX:
Form SSA-L4201 BK (01-2008) EF (01-2008)
Privacy Act Statement
Collection and Use of Personal Information
Sections 1611(c), 1612(a)(1), and 1631(e)(1) of the Social Security Act, as amended, authorize us
to collect the information on this form. The information you provide will help us verify wages or
resolve wage discrepancies for the individual named on this form. Your response is voluntary.
However, failure to provide the requested information may prevent an accurate and timely
decision on any claim filed or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for verifying
wages or resolving wage discrepancies. In accordance with 5 U.S.C. § 552a(b) of the Privacy
Act, however, we may disclose the information provided on this form in accordance with
approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, state and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and
4. To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer
matching programs compare our records with those of other Federal, state or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs. The law allows us to do this even if you do not agree
to it.
Additional information regarding this form, routine uses of information, and other Social Security
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.
| File Type | application/pdf |
| File Title | Printing L:\SUESFO~1\L4201A.FRP |
| Author | 191869 |
| File Modified | 2009-04-03 |
| File Created | 2009-04-03 |