Current SSA-L2765

2765-11
RETURN ONLY THE ORIGINAL (NOT A COPY) TO SSA

Form Approved
OMB No. 0960-0508

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Self-Employment Information

Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes-Barre, PA 18767-0039
Date:
Sequence Number:
Employer Number:
We need more information about self-employment earnings reported to us by the
Internal Revenue Service. Please complete the information on the back of this
letter and return it to us promptly. We cannot put these earnings on your Social
Security record until the name and Social Security number reported agree with our
records.
Name:
Social Security Number:
Reported Net Earnings from Self-Employment:
Tax Year:
THIS IS WHAT YOU NEED TO DO
1. If your Social Security card does not show your correct name or Social Security
number, or if you have lost your Social Security card, please call our toll-free
number, 1-800-772-1213, or contact your local Social Security office.
2. Compare the information shown above to the Schedule SE of your tax return and
your Social Security card.
3. If the name and number shown on the Social Security card:
- Agree exactly with the information shown above, contact your local Social
Security office. Do not mail this letter back to us.
- Do not agree with the information shown above, fill in the requested
information on the back of this letter. Then mail this letter to us in the
enclosed envelope.
4. Make sure that your future tax returns have your correct name and Social
Security number.

Si usted necesita una traducción de esta carta, por favor llámenos gratis
al, 1-800-772-1213, de lunes a viernes, desde las 7 a.m. hasta las 7 p.m. hora
del Este (TTY 1-800-325-0778 para las personas sordas o con problemas de
audición).
Please See Reverse

Form SSA-L2765-C1 (01/2012)

2765-11
RETURN ONLY THE ORIGINAL (NOT A COPY) TO SSA
REQUEST FOR SELF-EMPLOYMENT INFORMATION

1. Name shown on your Social Security card:

First

(Please Print--Use Black Ink or #2 Pencil)

Last

M.I.

2. Social Security number on your card:
3. Were the earnings shown on the front of this letter reported on your (joint/individual) tax
return?

If No, explain

If Yes, do the earnings reported belong to:

You

Your spouse

(Please check one)

Spouse's Name:

First

Last

M.I.

Spouse's SSN:
4. Have you ever used another name?

No

Yes

(Give other names used)

First

M.I.

Last

First

M.I.

Last

5. Daytime phone number where you can be reached
If you have any questions, you may call us toll-free at 1-800-772-1213 from 7 a.m. to
7 p.m., Monday through Friday, Eastern time. If you are deaf or hard of hearing, you
may call our TTY number, 1-800-325-0778. We can answer most questions over the phone.
You can also write or visit any Social Security office. If you do call or visit an office,
please have this letter with you. The office that serves your area is located at:

Enclosure:
Envelope
See Next Page

2765-11
RETURN ONLY THE ORIGINAL (NOT A COPY) TO SSA

DO NOT RETURN THIS PAGE
THE PRIVACY ACT
Section 205(a) of the Social Security Act allows us to ask for the information on
this letter. The information you give us will be used to give you credit for
earnings reported. You do not have to give us this information. However, without
the information we may not be able to give you credit for wages earned. We may
give this information to the Internal Revenue Service for tax administration
purposes or to the Department of Justice for investigating and prosecuting
violations of the Social Security Act.
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, State 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 not agree to it. Explanations about these and
other 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.

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 10 minutes to read the instructions,
gather the facts, and answer the questions. 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.