SSA-L4201BK Current Version

Form 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-L4201BK (7-2009)

EF (07-2009) Destroy prior editions

PAPERWORK/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.

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 30 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.

Form SSA-L4201 BK (07-2009) EF (07-2009)

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 (07-2009) EF (07-2009)

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 (07-2009) EF (07-2009)

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

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$

$
$
$

$
$
$

$
$
$

YEAR
___________
__ January
January

SOCIAL SECURITY NUMBER

GROSS WAGES
PAID IN MONTH

CAFETERIA PLAN
DEDUCTIONS

CHILD SUPPORT
GARNISHMENTS

OTHER

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$

$
$
$

$
$
$

$
$
$

4. ADDITIONAL INFORMATION/COMMENTS:

5. Signature

Date:

Title:
Employer
Telephone:

FAX:

Form SSA-L4201 BK (07-2009) EF (07-2009)

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

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$

$
$
$

$
$
$

$
$
$

YEAR
___________
__ January
January

SOCIAL SECURITY NUMBER

GROSS WAGES
PAID IN MONTH

$
$

CAFETERIA PLAN
DEDUCTIONS

CHILD SUPPORT
GARNISHMENTS

OTHER

$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$

$
$
$

$
$
$

$
$
$

4. ADDITIONAL INFORMATION/COMMENTS:

5. Signature

Date:

Title:
Employer
Telephone:

FAX:

Form SSA-L4201 BK (07-2009) EF (07-2009)