Social Security Administration OMB Approval No.
0960-0508
EARNINGS REPORT QUESTIONNAIRE
The earnings report had the following information:
Reported Employee Name SSN
Employer Name EIN
Wage Amount
What is your correct name? ______________ _______ ______________
(first) (middle) (last)
What is your correct Social Security Number? _____________________
What is your Date of Birth? __ __/__ __/__ __ __ __ (month, day, year)
Have you changed your name? Yes____ No____ Provide prior name:
How long have you worked for the employer shown? ______
If this company no longer employs you, what was your day last worked? _________________
Have you been assigned an Individual Tax Identification Number, also known as an ITIN? Yes ______ No ______
If yes, what is that number? ___________________________
Have you ever received a Social Security Statement of earnings from the Social Security Administration? Yes _____ No ______
If yes, did you review it to see if it contained all of your earnings? Yes ______ No ______
Have you ever had problems in the past with having your earnings correctly reported to the Social Security Administration? Yes ____ No _____
If yes, please explain the problem(s) you experienced: _______________________________________________________
| File Type | application/msword |
| Author | 889123 |
| Last Modified By | 889123 |
| File Modified | 2010-07-26 |
| File Created | 2010-07-26 |