SSA-L725 - Current

Form SSA-L725 (06-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0034

SOCIAL SECURITY
Date:
Refer to:

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

Ending Date of Employment:

Beginning Date of Employment:

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

Year:
January

$

April

$

July

$

October

February

May

August

November

March

June

September

December

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

$

Page 2 of 3
If the amount of wages for each month is the same, enter the
monthly amount here.

Year:
January

$

April

$

July

$

October

February

May

August

November

March

June

September

December

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

Year:
January

$

April

$

July

$

October

February

May

August

November

March

June

September

December

$

April

July

$

$

October

February

May

August

November

March

June

September

December

$

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

Year:
January

$

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

Year:
January

$

$

April

July

$

$

October

February

May

August

November

March

June

September

December

$

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

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Privacy Act Statement
Collection and Use of Personal information
Sections 205(a) and 223(d) 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 and timely decision on any claim filed or could result in the loss of
benefits.
We will use the information to verify wages or resolve wage discrepancies, and evaluate and determine if the
individual named on this form meets eligibility requirements for benefits. We may also share your 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 third party contacts (e.g., employers and private pension plan) in situations where the party to be
contacted has, or is expected to have, information relating to the individual’s capability to manage affairs or
eligibility for or entitlement to benefits under the Social Security program when the data are needed to
establish the validity of evidence or to verify the accuracy of information presented by the individual, and it
concerns the individual’s eligibility for benefits under the Social Security program.
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 Notices (SORN) 60-0059,
entitled Earnings Recording and Self-Employment Income System, 60-0089, entitled Claims Folders Systems,
and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy/sorn.html.

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. 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 above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401.