SSA-L4002, Request for Employer Information

SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0508 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-L4002 SSA-L4002, Request for Employer Information Form
SSA-L4002 Request for Employer Information SSA-L4002 (revised).pdf Form
SSA-L4002 (current).pdf Current SSA-L4002 IC Document

Information Collection (IC) Details

IC Title:	SSA-L4002, Request for Employer Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 422.120

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4002	Request for Employer Information	SSA-L4002 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 121,679	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	121,679	121,679
Annual IC Time Burden (Hours)	20,280	20,280
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L4002	SSA-L4002 (current).pdf	01/06/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.