Form SSA-L3365 Request for Employee Information

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Form Approved
OMB No. 0960-0508

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

Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes-Barre, PA 18767-0039
Date:
Sequence Number:
Employer Number:
We need more information so that we can give you credit for your earnings from
the company and for the year shown below. We cannot put these earnings on your
Social Security record until the name and Social Security number reported to us
match our records. Unless this problem is corrected, you may not get retirement,
disability, survivors or other benefits that you are due.
Company Name:
Employee's Name:
Social Security Number:
Reported Earnings:
Tax Year:
THIS IS WHAT YOU NEED TO DO
1. If your Social Security card does not show your correct name or Social Security
number, or if you have lost your Social Security card, please call our toll-free
number, 1-800-772-1213, or contact your local Social Security office.
2. Compare the information shown above to your Form W-2(s) and your Social
Security card.
If the name and number shown on the Social Security card agree exactly with
the information shown above, contact your local Social Security office so that we
can find out why our records do not match what was reported for you by your
employer. Do not mail this letter back to us.
If the name and number shown on the Social Security card do not agree with
the information shown above, fill in the requested information on the reverse side
of this letter, and mail it to us in the enclosed envelope. If you have been using
an incorrect name or Social Security number, or your employer has been
reporting earnings for you under an incorrect name or Social Security number,
you must also correct this information with your employer.
IMPORTANT: THE FACT THAT YOU HAVE RECEIVED THIS LETTER DOES NOT, IN AND
OF ITSELF, ALLOW YOUR EMPLOYER TO CHANGE YOUR JOB, LAY YOU OFF, FIRE
YOU OR TAKE OTHER ACTION AGAINST YOU. IF YOU THINK YOUR EMPLOYER IS
DISCRIMINATING AGAINST YOU BECAUSE YOUR NAME AND SOCIAL SECURITY
NUMBER DO NOT MATCH OUR RECORDS, SEE THE ATTACHED INFORMATION ON
IMPORTANT PROTECTIONS OF YOUR RIGHTS.
For Spanish-speaking individuals: Esta carta contiene información importante.
3 para los detalles.

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Form SSA-L3365-C1 (01/2011)

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Most problems with names and Social Security numbers that do not match our
records are the result of mistakes and do not involve intentional fraud. We want
to work with you and your employer to correct your earnings record and to make
sure that you receive credit for all of your work under the Social Security
program.
Please fill out the following form if the name and number shown on your Social
Security card do not agree with the information on page one of this letter. Please
take this action now to make sure you receive any retirement, disability, survivors
or other benefits owed to you.
For Spanish-speaking individuals: Esta carta pide información sobre las
ganancias que su empleador informó. Si usted necesita una traducción de
esta carta, por favor llámenos gratis al, 1-800-772-1213, de lunes a viernes,
desde las 7 a.m. hasta las 7 p.m.
REQUEST FOR EMPLOYEE INFORMATION
1. Name shown on your Social Security card

First

(Please Print--Use Black Ink or #2 Pencil):

M.I.

Last

2. Social Security number on your card:
3. Does the amount of reported earnings on the front

of this letter match any Form W-2 you received for
the tax year shown?

4. Have you ever used another name?

First

No

M.I.

Yes

Yes

No

(Explain)

(Give other names used)

Last

5. Daytime phone number where you can be reached

NOTE:

Do NOT send a copy, or original, of a Form W-2c with this letter.

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KEEP THIS PAGE--IT INCLUDES IMPORTANT INFORMATION
Your employer may not take action against you based on this letter.
If you think that any action against you is related to labor union activities or
union organizing activities, you may contact the National Labor Relations Board
(NLRB), an agency of the U.S. government (www.nlrb.gov). Check your local
directory for the nearest NLRB office in your area.
If you think that any action against you is related to your race, color, sex,
religion, national origin, age or disability, you may call the Equal Employment
Opportunity Commission (EEOC) toll-free at 1-800-669-4000, or 1-800-669-6820 (TDD
for the deaf or hard of hearing), or visit the website at www.eeoc.gov.
If you have questions or concerns about unfair practices by your employer that
may be related to your national origin or citizenship status, you may call the
Office of Special Counsel for Immigration-Related Unfair Employment Practices
toll-free at 1-800-255-7688, or 1-800-237-2515 (TDD for the deaf or hard of hearing).
Within the Washington, D.C., metropolitan area, call 202-616-5594.
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For Spanish-speaking individuals:
GUARDE ESTA CARTA - CONTIENE INFORMACIÓN IMPORTANTE
Su empleador no puede tomar acción en su contra basándose en esta carta.
Si usted piensa que cualquier acción en su contra está relacionada con las
actividades del sindicato de trabajadores o actividades organizadas por el
sindicato, usted se puede comunicar con la Junta Nacional de Relaciones
del Trabajo (NLRB, siglas en inglés), agencia del gobierno de los Estados
Unidos (www.nlrb.gov). Busque en su directorio local la oficina de la Junta
Nacional de Relaciones del Trabajo más cercana.
Si usted cree que cualquier acción en su contra está relacionada con su
raza, color, sexo, religión, origen nacional, edad o incapacidad, puede
llamar gratis a la Comisión de Igualdad de Oportunidades de Empleo
(EEOC, siglas en inglés) al 1-800-669-4000 ó 1-800-669-6820 (TDD para
las personas sordas o con problemas de audición), o puede visitar
www.eeoc.gov/es/index.html en el Internet.
Si usted tiene preguntas o dudas sobre prácticas injustas por parte de su
empleador, que pueden estar relacionadas con su origen nacional o estado
legal, puede llamar gratis a la Oficina del Consejero Especial para
Prácticas de Empleo Injustas Relacionadas a la Condición de Inmigrante
al 1-800-255-7688 ó 1-800-237-2515 (TDD para las personas sordas o con
problemas de audición). Dentro del área metropolitana de Washington,
D.C., llame al (202) 616-5594.
El hecho de que usted haya recibido esta carta no constituye una razón, de
por sí, para que su empleador lo cambie de trabajo, suspenda, despida o tome
alguna acción adversa en su contra.

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If you have any questions, you may call us toll-free at 1-800-772-1213. We can
answer most questions over the phone. You can also write or visit any Social
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:

If you need an interpreter to conduct Social Security business, we will supply one
on request, free of charge. If you want us to supply the interpreter, please call
1-800-772-1213 before you come to the office and tell us what language you prefer to
speak.
Si usted necesita un intérprete para tramitar sus asuntos con el Seguro
Social, le podemos proveer uno, si lo pide, completamente gratis. Si usted
desea que le proveamos un intérprete, por favor llame al 1-800-772-1213
antes de venir a la oficina y háganos saber qué idioma prefiere hablar.

Enclosure:
Envelope

See Revised Privacy Act Statement Attached
THE PRIVACY ACT

Section 205(a) of the Social Security Act allows us to ask for the information on this
letter. The information you give us will 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 information to the
Internal Revenue Service for tax 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 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 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 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 you about 10 minutes to read the instructions, gather the
necessary facts, and answer the questions. You may send comments on our time estimates
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
related to our time estimate to this address, not the completed form.

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this
information. We will use this information to give you credit for earnings reported.
Completion of this form is voluntary; however, without the information we may not be
able to give you credit for wages earned.
We rarely use the information you supply for any purpose other than what is stated
above. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency 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 comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by 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.
A complete list of routine uses for this information is available in our System of Records
Notices entitled, Earnings Recording and Self-Employment Income System (60-0059).
This notice, additional information regarding this form, routine uses of information, and
our programs and systems are available on-line at www.socialsecurity.gov or at your
local Social Security office.