SSA-L4201 - Current

SOCIAL SECURITY
Important Information

Form Approved
OMB No. 0960-0138

Office Address:

Telephone Number:
FAX Number:
Office Hours:
Date:
We are asking for your help in obtaining wage information about the employee named on the
attached pages. Please complete sections 1 through 3 of the form if they are indicated, and section 5
in all cases.
If you prefer to send a payroll printout instead of completing the form, please include an explanation
of the items on the printout.
For your convenience, we are enclosing a postage-paid reply envelope. If a fax number is shown
above, you may instead fax the information to that number.
We appreciate your help in this matter. If you have any questions, please call the telephone number
above and ask for
.

Enclosure(s)
Stamped Reply Envelope

Field Office Manager:

Page 1

Form SSA-L4201-BK (03-2015) ef (03-2015)
Destroy prior editions

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 clearance requirements of 44 U.S.C. § 3507, as amended by
Section 1 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 30 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is listed under the U.S. Government agencies in your telephone directory or you may call
Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time
estimates above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Page 2

Form SSA-L4201-BK (03-2015) ef (03-2015)

EMPLOYEE NAME

SOCIAL SECURITY NUMBER REFERENCE NUMBER

1. Current Wages. Please show the following:
• Is the individual named above still employed with your company?
Yes

No

(If employment terminated, show the date last paid and the date last worked in the blocks
below. It is not necessary to complete the rest of this section. If employment has NOT
terminated, skip the first two blocks below and complete the rest of this section.)
Date Last Worked (MMDDYY)

Date Last Paid (MMDDYY)

Current rate of pay (per hour, day, week, piece, etc.):

$

per

$

per

Amount worked per pay period (in hours, days, pieces, etc.):
Day of week or date(s) of month on which paid:
How often paid (weekly, biweekly, monthly, etc.):
Date last paid (month, day, year):
Rate of overtime pay (per hour, day, week, etc.):
Average overtime per pay period (no. of hours):
Please describe any changes you expect in any of the information shown above:

2. DEDUCTIONS FROM GROSS WAGES
• Does the employee participate in a CAFTERIA PLAN?
Yes

No

A cafeteria plan is a pre-tax plan undersection 125 of the Internal Revenue Code. Under a
cafeteria plan, employees can choose, cafeteria-style, from a menu of two or more qualified
benefits, or cash. Qualified benefits include, but are not limited to, accident and health
plans, group term life insurance plans, dependent care assistance plans, and certain stock
bonus plans undersection 401(k)(2) (but not 401(k)(1)) of the Internal Revenue Code.
Cafeteria plans are often shown on pay slips as FLEX, CHOICES, Sec. 125, café plan, etc.
• Are any of the employee's wages garnished for child support?
Yes

No
Page 3

Form SSA-L4201-BK (03-2015) ef (03-2015)

EMPLOYEE NAME

SOCIAL SECURITY NUMBER REFERENCE NUMBER

3. PRIOR WAGES. Please read the following instructions and provide the information requested
on the following page(s).
What We Need To Know About Wages and Deductions
Wages
We need to know the amount of gross wages paid to the employee in each of the months
checked on the back of this page and any additional pages. Base these amounts on actual
paydays in the month, not the ending dates of pay periods. For example, wages earned in a
pay period ending on May 29 but actually paid on June 5 would be included in the total gross
wages paid in June. If no wages were paid to the employee in a month that is checked, please
show "none."

Be sure to include in gross wages:
• Tips
• Bonuses
• Overtime
• Holiday and vacation pay
• The dollar value of payments in kind (meals or lodging, for example)
• Any contributions under a salary reduction agreement to a cafeteria plan as defined in section
125 of the Internal Revenue Code
• Garnished child support.
Do not include in gross wages any advance earned income tax credit payments.
Deductions
Please also provide the amount of any cafeteria plan deductions, garnished child support, or
any other item indicated at the top of these columns to the right of the gross wages. Please
show "none," if applicable. Completion of the "OTHER" column is only needed when a specific
item is listed at the top of that column.

Page 4

Form SSA-L4201-BK (03-2015) ef (03-2015)

EMPLOYEE NAME
GROSS WAGES
PAID IN MONTH

YEAR:

OTHER

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

October
November
December

$
$

$
$

$
$

$
$

$

$

$

$

January
February
March
April
May
June
July
August
September
October
November
December

5.

CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS

January
February
March
April
May
June
July
August
September

GROSS WAGES
PAID IN MONTH

YEAR:

4.

SOCIAL SECURITY NUMBER REFERENCE NUMBER

$
$
$
$
$
$
$
$
$
$
$

CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS

OTHER

$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$
$
Additional Information/Comments:

$

$

Signature:
Title:

Date:

Employer's Name:
Telephone:

FAX:
Page 5

Form SSA-L4201-BK (03-2015) ef (03-2015)

EMPLOYEE NAME
GROSS WAGES
PAID IN MONTH

YEAR:

OTHER

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$

October
November
December

$
$

$
$

$
$

$
$

$

$

$

$

January
February
March
April
May
June
July
August
September
October
November
December

5.

CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS

January
February
March
April
May
June
July
August
September

GROSS WAGES
PAID IN MONTH

YEAR:

4.

SOCIAL SECURITY NUMBER REFERENCE NUMBER

$
$
$
$
$
$
$
$
$
$
$

CAFETERIA PLAN CHILD SUPPORT
DEDUCTIONS
GARNISHMENTS

OTHER

$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$
$
$
$
$
$
$
$
$
$
$

$
$
Additional Information/Comments:

$

$

Signature:
Title:

Date:

Employer's Name:
Telephone:

FAX:
Page 6

Form SSA-L4201-BK (03-2015) ef (03-2015)