Current SSA-L725

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.
Sincerely yours,
Enclosure

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. $

January $

April

July

February

May

August

November

March

June

September

December

$

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

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

September

December

July

$

October $

$

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

Year
January $

April

July

February

May

August

November

March

June

September

December

$

October $

$

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)

Privacy Act Statement Collection and
Use of Personal Information
Sections 205(a), 205(c)(2), and 233 of the Social Security Act, as amended, the Federal Records Act
of 1950 (64 Stat. 583), the Employee Retirement Income Security Act of 1974 (Pub. L. 93-406), the
Coal Industry Retiree Health Benefit Act of 1992 (Pub. L. 102-486, 106 Stat. 2776) and our
regulations at 20 CFR 404.703, authorize us to collect this information. We will use the information
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 faciliate 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.
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. The OMB control number for this collection is 0960-0034. We estimate that it will take
about 40 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate to : SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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