Form SSA-L725 Letter to Employer Requesting Information About Wages Ea

Fonn Approved
OMB No. 0960-0034

SOCIAL SECURITY

Refer to:
Date:

•
Social Security

Number
Worker's Name:

Telephone:
Area Code:

So that we may detennine the above-named person's eligibility for Social Security benefits,
please furnish the amount of gross wages earned by the employee in each of the months
checked below. If no wages were earned in a month, show "none. "
Please note that we need to know the amounts earned for services performed within the
calendar month, regardless of the amounts paid. If the employee received cash tips, include
the amount in the totals for the month.
We appreciate your cooperation in furnishing this information. An envelope requiring no
postage is enclosed for your convenience.
Sincerely yours,
Enclosure
If the amount of wages for each month is the same, enter the
monthly amount here. $

Year

0
0
0

January
February
March

$

o
o
o

April

o
o
o

$

May
June

July

o
o
o

$

August
September

October $
November
December

o See other side for additional years (check if applicable).
PRIVACY ACT NOTICE: This report is authorized by law 20 CFR 404.103. While your response is volunlary. your cooperation is needed to assure that the above named

person's wage record is accurate and that a correct detennination of eligibility for Social Security benefits is made.

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. Slate 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 nO! agree to it.

Explanation about these and otber 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.

See Revised Privacy Act Notice

Paperwork Reduction Act Statement - This information COllection meets the requirements of 44 U.S.C. § 3501. 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 cootrol number. We estimate that it will take about 30 to 50
minutes to read the instructions. gather the facts. and answer the questions. SEND TIlE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To
find the nearest office. call 1-800-772-1213. Send!!!!!1. comments 011 olir time estimate afJove to: oSSA, 1338 AllJlex Bllildillg. Baltimore. MD 2/235-040/.
I dedare under penalty of perjury that I have examined all the information on this form. and on any accompanying statements or fonus. and It Is true and correct to
the best of my knowledge.

EMPLOYER
SIGNATURE

See Revised Paperwork Reduction Act Statement
AREA CODE AND TELEPHONE NO.
TITLE

DATE
Form SSA-L725 (06-2003) EF (05-2005)
Destroy Prior Editions

If the amount of wages for each month is the same, enter the
monthly amount here. $

Year
D

January $

DApril

0
0

February

o

March

DJune

Dluly

$

o
o

May

$

August
September

o
o
o

October $
November
December

If the amount of wages for each month is the same, enter the
monthly amount here $

Year

o

0

January

D

February

DMay

D

August

D

November

D

March

DJune

D

September

D

December

$

April

DJUly

$

$

DOctober $

If the amount of wages for each month is the same, enter the
monthly amount here $

Year
D

lanuary $

DAprii

D

February

DMay

D

March

DIune

D

October $

DAugust

D

November

D

DDecember

DJuly

$

$

September

If the amount of wages for each month is the same, enter the
monthly amount here $

Year
D

January $

DAPrii

D

February

DMay

D

August

DNovember

D

March

Dlune

D

September

DDecember

DJuly

$

$

DOctober $

I

I declare under penalty of perjury that I have examined all the information on this form,
and on any accompanying statements or forms, and it is true and correct to the best of my
knowledge.
SIGNATURE

GO

ITITLE

u.s. GOVERNMENT PRINTING OFFICE: 2008- 339-224/00289

Form SSA-L725 (06-2003) EF (05-2005)

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
20 CFR 404.703 authorizes us to collect this information. The information you provide
will be used to determine your employee’s eligibility for Social Security Benefits.
The information you furnish on this form is voluntary. However, we need your
cooperation to assure that the above-named person’s wage record is accurate and that we
can correctly determine eligibility for Social Security benefits.
We rarely use the information you supply for any purpose other than for determining
continued eligibility. 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 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.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 about 40
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING 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.