SSA-95-SM - Current

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Date: MM/DD/YYYY

Form Approved
OMB No. 0960-0432
EMPLOYER QUESTIONNAIRE
SSA HAS NO RECORD OF EMPLOYER REPORT

The IRS records show that you paid Social Security and/or Medicare taxes on the wages that appear
below. However, SSA does not have a record of your Forms W-2 and W-3 for these wages. The IRS
requires you to send Forms W-2 to SSA.
IRS Data 941, 943, 944 or Schedule H (Household Employment Taxes) for
Tax Year: YYYY
EIN: 99-9999999
Employer Name: Employer Name
Employee Soc. Security Wage Totals:
Employee Soc. Security Tip Totals:
Employee Medicare Wage/Tip Totals:

$999,999.00
$999,999.00
$999,999.00

CHECK AND COMPLETE
Check and complete any items that apply to your wage report for the tax year shown above. If you send a
wage report that shows a different total from the amount shown above, please explain why in number 6.

1. ( ) I did not file Forms W-2 with SSA. I am now taking the following action (check one):
( ) Enclosed is the original Copy A of paper Forms W-2 and W-3, or
( ) Sending SSA an electronic file.
Caution: If you are filing electronically, be sure to check the box indicating the submission is in
response to a reconciliation notice. When you return this questionnaire, include a copy of the Business
Services Online (BSO) receipt showing the wage file identifier (WFID) as proof of filing.
2. ( ) I filed Forms W-2 under the EIN for the TY shown above. I am now taking the following action
for the wages I previously reported (check one):
( ) Enclosed are legible copies of paper Forms W-2 and W-3, or
( ) Enclosed is a copy of the Business Services Online (BSO) receipt showing the wage file identifier
(WFID) as proof of filing.

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3. ( ) I filed Forms W-2 under EIN __________ , rather than the EIN shown above. Submit Forms W3c
and W2c to correct the EIN wages were originally reported under.
4. ( ) I filed but cannot locate my copies of Forms W-2 and W-3. I am now taking the following action
(check one):
( ) Enclosed are duplicate copies of paper Forms W-2 and W-3,or
( ) Sending SSA an electronic file.
See “Caution” shown under Item #1 above.
5. ( ) I was self-employed.
( ) I was not required to file Forms W-2 with SSA. Attached are legible copies of Schedule SE or
Schedule C that show SE tax.
( ) I had employees working for me during the year. Attached are legible copies of Forms W-2 for
those employees.
6. ( ) Other ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________
Your Name and Title

( ) ______________________
Daytime Phone, with Area Code

INFORMATION ABOUT THE DATA YOU SEND SSA
The name, Social Security number, and wage amounts on the Forms W-2 must be readable and complete.
If we cannot read all information on the documents you submit, or if any of these items are missing, we
cannot add the wages to the employee's wage record. If you need blank copies of the Forms W-2 or W-3,
call the IRS at 1-800-829-3676. If your copies of the Forms W-2 are illegible, please prepare duplicates
on blank copies of the Forms W-2. Make sure the Forms W-2 show the correct year for the wages you
report.
Note: If you send 250 or more wage items to us, you must file your wage reports electronically in
accordance with Publication 42-007: Specifications for Filing Forms W-2 Electronically (EFW2). For
more information, please go to our website at www.socialsecurity.gov/employer or call SSA's Employer
Reporting Branch at 1-800-772-6270 Monday through Friday, 7:00 a.m. to 7:00 p.m., Eastern Time.

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RETURN THIS QUESTIONNAIRE
Please send all requested information to:
Social Security Administration
P.O. Box 33021
Baltimore, Maryland 21290-3021

Important: Do not send cash, checks, or money orders to SSA. Send your tax payments directly to the
Internal Revenue Service.

Privacy Act Statement
Collection and Use of Personal Information
Section 205(c)(2)(A) of the Social Security Act, as amended, and C.F.R. 26 § 31.6051-2 allow us
to collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information will result in a referral of your case to the Internal Revenue
Service
We will use the information to establish and maintain records of the amount of wages paid for
individual employees. We may also share your information for the following purposes, called
routine uses:
1. To the Department of the Treasury for investigating alleged forgery, or unlawful
negotiation of Social Security checks; and Tax administration as defined in 26 U.S.C.
6103 of the Internal Revenue Code; and
2. To Federal, State, or local agencies (or agents on their behalf) for the purpose of
validating Social Security numbers used in administering cash or non-cash income
maintenance programs or health maintenance programs (including programs under the
Social Security Act).
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
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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 30 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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