Employer Report of Special Wage Payments--No Response to Question #6

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 203(f), 205(c) and 233 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from making an accurate determination regarding the amount
of Social Security benefits payable to the individual for the year in question.
We will use the information you provide to make a determination concerning the amount of
Social Security benefits payable to the individual. We may also share this information for the
following purposes, called routine uses:
•

To any source that has, or is expected to have, information that the Social Security
Administration (SSA) needs in order to establish or verify a person’s eligibility for a
certificate of coverage under a Social Security agreement authorized by section 233 of
the Social Act; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting the
SSA in the efficient administration of our programs.

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 Recordings and Self-Employment Income System, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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
(OMB) control number. We estimate that it will take about 20 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.