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

Form Approved

OMB No.0960-0034

SOCIAL SECURITY
Refer to:
Date:
•
Social Security
Number
Worker's Name:
Telephone:
Area Code:

So that we may determine 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. A computerized printout in any format may
be substituted for the enclosed form.
Sincerely yours,

Enclosure
Beginning Date of Employment:______ Ending Date of Employment:______

Year
January $

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

July $

October $

February

May

August

November

March

June

September

December

See other side for additional years (check if applicable).
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.
EMPLOYER
NAME

AREA CODE AND TELEPHONE NO.
TITLE

DATE
Form SSA-L725-F3 (06-2012) EF (06-2012)

Destroy Prior Editions

Year

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

January $

April

February

May

August

November

March

June

September

December

July

$

$

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

Year

July

October $

January $

April

February

May

August

November

March

June

September

December

$

$

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

Year
January $

April

February

May

August

November

March

June

September

December

$

July

October $

$

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

Year
January $

April

February

May

August

November

March

June

Septembe

December

July

$

October $

$

r

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.
NAME

TITLE

DATE

Form SSA-L725-F3 (06-2012) EF (06-2012)

SSA will insert the following Privacy Act Statement into the form at its next scheduled
reprinting:
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.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim filed or
could result in loss of benefits.
We rarely use the information you supply for any purpose other than for wages or resolving
wage discrepancies. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records 60-0090, entitled Master Beneficiary Record,
and 60-0103, entitled Supplemental Security Income Record. Additional information about
these and other system of records notices and our programs is available from our Internet website
at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.