Form SSA-L3365 Request for Employee Information

DO
o

.

,

~

. .

A

1

•

•

331.5-10
NOT COPY

j

Form Approved

j •

OMB No- »9«0-

Social Security Administration

Retirement, Survivors, and Disability Insurance
Request for Employee Information

Social Security Administration
Data Operations Center
P.O. Box 39
Wilkes-Barre, PA

18767-0039

Date:

Sequence Number:
Employer Number:

We need more information so that we can give you credit for your earnings from
the company and for the year shown below. We cannot put these earnings on your
Social Security record until the name and Social Security number reported to us
match our records. Unless this problem is corrected, you may not get retirement,
disability, survivors or other benefits that you are due.
Company Name:
Employee's Name:

Social Security Number:
Reported Earnings:
Tax Year:

THIS IS WHAT YOU NEED TO DO
1. If your Social Security card does not show your correct name or Social Security
number, or if you have lost your Social Security card, please call our toll-free
number, 1-800-772-1213, or contact your local Social Security office.

2. Compare the information shown above to your Form W-2(s) and your Social
Security card.
• If the name and number shown on the Social Security card agree exactly with
the information shown above, contact your local Social Security office so that we
can find out why our records do not match what was reported for you by your
employer.

Do not mail this letter back to us.

* If the name and number shown on the Social Security card do not agree with
the information shown above, fill in the requested information on the reverse side
of this letter, and mail it to us in the enclosed envelope. If you have been using
an incorrect name or Social Security number, or your employer has been
reporting earnings for you under an incorrect name or Social Security number,
you must also correct this information with your employer.

IMPORTANT: THE FACT THAT YOU HAVE RECEIVED THIS LETTER DOES NOT, IN AND

OF ITSELF, ALLOW YOUR EMPLOYER TO CHANGE YOUR JOB, LAY YOU OFF, FIRE
YOU OR TAKE OTHER ACTION AGAINST YOU.

IF YOU THINK YOUR EMPLOYER IS

DISCRIMINATING AGAINST YOU BECAUSE YOUR NAME AND SOCIAL SECURITY
NUMBER DO NOT MATCH OUR RECORDS, SEE THE ATTACHED INFORMATION ON
IMPORTANT PROTECTIONS OF YOUR RIGHTS.
For Spanish-speaking individuals: Esta carta contiene informacion importante.

Vea la pagina

3 para los detalles.
Please See Reverse
Form SSA-L3365-C1

33bS-10

DO

NOT

COPY

Most problems with names and Social Security numbers that do not match our
records are the result of mistakes and do not involve intentional fraud. We want
to work with you and your employer to correct your earnings record and to make
sure that you receive credit for all of your work under the Social Security
program.

Please fill out the following form if the name and number shown on your Social
Security card do not agree with the information on page one of this letter. Please
take this action now to make sure you receive any retirement, disability, survivors
or other benefits owed to you.

For Spanish-speaking individuals:

Esta carta pide information sobre las

ganancias que su empleador informo. Si usted necesita una traduccion de
esta carta, por favor Uamenos gratis al, 1-800-772-1213, de lunes a viernes,
desde las 7 a.m. hasta las 7 p.m.

REQUEST FOR EMPLOYEE INFORMATION

1. Name shown on your Social Security card

First

(Please Print-Use Black Ink or #2 Pencil):

M.I.

Last

2. Social Security number on your card:
3. Does the amount of reported earnings on the front
of this letter match any Form W-2 you received for
the tax year shown?

4. Have you ever used another

First

na me?

Nc»

M.I.

No

Yes

Yes

(Explain)

(Give other names used)

Last

5. Daytime phone number where you can be reached

NOTE:

Do NOT send a copy, or original, of a Form W-2c with this letter.

See Next Page

DO

33L5-10
NOT COPY

KEEP THIS PAGE-IT INCLUDES IMPORTANT INFORMATION
Your employer may not take action against you based on this letter.

• If you think that any action against you is related to labor union activities or
union organizing activities, you may contact the National Labor Relations Board
(NLRB), an agency of the U.S. government (www.nlrb.gov). Check your local
directory for the nearest NLRB office in your area.

• If you think that any action against you is related to your race, color, sex,

religion, national origin, age or disability, you may call the Equal Employment

Opportunity Commission (EEOC) toll-free at 1-800-669-4000, or 1-800-669-6820 (TDD
for the deaf or hard of hearing), or visit the website at www.eeoc.gov.

• If you have questions or concerns about unfair practices by your employer that
may be related to your national origin or citizenship status, you may call the

Office of Special Counsel for Immigration-Related Unfair Employment Practices
toll-free at 1-800-255-7688, or 1-800-237-2515 (TDD for the deaf or hard of hearing).
Within the Washington, D.C., metropolitan area, call 202-616-5594.
Please See Reverse

For Spanish-speaking individuals:

GUARDE ESTA CARTA - CONTIENE INFORMACI6N IMPORTANTE
Su empleador no puede tomar accion en su contra basandose en esta carta.
• Si usted piensa que cualquier accion en su contra esta relacionada con las
actividades del sindicato de trabajadores o actividades organizadas por el
sindicato, usted se puede comunicar con la Junta Nacional de Relaciones

del Trabajo (NLRB, siglas en ingles), agenda del gobierno de los Estados
Unidos (www.nlrb.gov). Busque en su directorio local la oficina de la Junta
Nacional de Relaciones del Trabajo mas cercana.
• Si usted cree que cualquier accion en su contra esta relacionada con su
raza, color, sexo, religion, origen nacional, edad o incapacidad, puede
llamar gratis a la Comision de Igualdad de Oportunidades de Empleo
(EEOC, siglas en ingles) al 1-800-669-4000 6 1-800-669-6820 (TDD para
las personas sordas o con problem as de audicion), o puede visitar
www.eeoc.gov/es/index.html en el Internet.
• Si usted tiene preguntas o dudas sobre practices injustas por parte de su
empleador, que pueden estar relacionadas con su origen nacional o estado
legal, puede llamar gratis a la Oficina del Consejero Especial para
Practicas de Empleo Injustas Relacionadas a la Condicion de Inmigrante
al 1-800-255-7688 6 1-800-237-2515 (TDD para las personas sordas o con
problem as de audici6n).

Dentro del area metropolitana de Washington,

D.C., llame al (202) 616-5594.

El hecho de que usted haya recibido esta carta no constituye una razon, de
por si, para que su empleador lo cambie de trabajo, suspenda, despida o tome
alguna accion adversa en su contra.

Vea al dorso

3315-10

DO NOT COPY

If you have any questions, you may call us toll-free at 1-

2gSg&5gXgS3E?Z&

antes de venir a la oficina y haganos saber que idioma prefiere hablar

Social Security. (ZdnunhViaUan
Enclosure:
Envelope

PRIVACY ACT STATEMENT

Collection and Use of Personal Information

Sections 205(a) and 205(c)(2)(A) 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 crediting your earned wages.

We will use the information you provide to give you credit for earnings reported. We may also
share this information for the following purposes, called routine uses:

1. To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes; and

2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration 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 to 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, 600059, entitled Earnings Recordings and Self-Employment Income System. Additional
information and a full listing of all our SORNs are available on our website at
www.socialsecuritv.gov/foia/bluebook.

See Revised Privacy Act & PRA
Statements attached
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
10 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 21235-0001.

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 205(a) and 205(c)(2)(A) 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 crediting the proper earnings record.
We will use the information you provide to ensure wages and self-employment income are
properly identified and credited to the appropriate earnings record. We may also share the
information for the following purposes, called routine uses:
•

To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes; and,

•

To contractors or other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its 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 Recording 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 10 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.