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:

Area Code:
Telephone:

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:___________

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

Year
January $

April $

July

$

February

May

August

November

March

June

September

December

October

$

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

Form SSA-L725-F3 (06-2015) UF (06-2015)
Destroy Prior Editions

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

Year
January $

April $

July

February

May

August

November

March

June

September

December

$

October $

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

Year
January $

April $

July

February

May

August

November

March

June

September

December

$

October $

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

Year
January $

April $

July

February

May

August

November

March

June

September

December

$

October $

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

Year

April $

July

February

May

August

November

March

June

September

December

January

$

$

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.
EMPLOYER

NAME

AREA CODE AND TELEPHONE NO.
TITLE

DATE

Form SSA-L725-F3 (06-2015) UF (06-2015)

See Revised Privacy Act
Statement Attached

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.
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 (06-2015) UF (06-2015)