Form SSA-95-SM Employer Questionnaire--SSA Has No Record of Employer Re

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Date: MM/DD/YYYY

Form Approved
OMB No. 0960-0432

EMPLOYER QUESTIONNAIRE
SSA HAS NO RECORD OF EMPLOYEES’ EARNINGS
The IRS’s records show that you paid Social Security and/or Medicare taxes on the wages and
tips that appear below. However, SSA doesn’t have a record of your Forms W-2 and W-3 for
these wages. The IRS requires you to send your employees’ Forms W-2 to SSA.
Tax Year: YYYY
Employer Identification Number (EIN): 99-9999999
Employer’s Name: Employer’s Name

Social Security Wages
Social Security Tips
Medicare Wages

SSA Processed

IRS Processed

$0.00
$0.00
$0.00

$999,999.99
$999,999.99
$999,999.99

CHECK AND COMPLETE
Check and complete any items that apply to your wage reports for EIN 999999999 and tax year
9999.
1. I didn’t file Forms W-2 and W-3 with SSA. I’m taking the following action (check one):
___

I’m filing Forms W-2 and W-3 electronically, either through the Business
Services Online (BSO) website or through a third party, such as a payroll service.
The Wage File Identifier (WFID) is ________________________________
(optional).

___

I’m enclosing legible copies of Forms W-2 and W-3.

Note: If you’re filing 250 or more Forms W-2 with SSA, you must file your wage
reports electronically in accordance with the General Instructions for Forms W-2 and W3, at https://www.irs.gov/pub/irs-pdf/iw2w3.pdf. You can sign in or register for an
account at www.ssa.gov/employer to report your wages electronically.
2. I filed Forms W-2 and W-3 under a different EIN. I’m taking the following action (check
one):
___

I’m filing Forms W-2c and W-3c to correct my reporting errors because I filed
Forms W-2 and W-3 using an incorrect EIN.

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Note: For assistance on how to fill out Forms W-2c and W-3c to correct your wages,
visit https://www.irs.gov/pub/irs-pdf/iw2w3.pdf.
___

I’m not taking action because I was assigned more than one EIN for my
organization. Instead of filing under EIN 999999999, I filed under EIN
_________________________. I’m requesting that SSA associate those wages
with EIN 999999999.

___

I’m not taking action because EIN 999999999 has been incorporated into EIN
_________________________. All wages should be reported under this EIN.

3. I was self-employed. I’m taking the following action (check one):
___

I’m filing Forms W-2 and W-3 electronically, either through the Business
Services Online (BSO) website or through a third party, such as a payroll service
because I had employees (including myself) during tax year 9999. The Wage File
Identifier (WFID) is ________________________________ (optional).

___

I’m enclosing legible copies of Forms W-2 and W-3 because I had employees
(including myself) during tax year 9999.

Note: If you’re filing 250 or more Forms W-2 with SSA, you must file your wage
reports electronically in accordance with the General Instructions for Forms W-2 and W3, at https://www.irs.gov/pub/irs-pdf/iw2w3.pdf. You can sign in or register for an
account at www.ssa.gov/employer to report your wages electronically.
___

I’m providing copies of IRS Form 1099-MISC to contract employees.

Note: Contact the IRS to determine corrective action.
___

I’m providing copies of Schedule SE or Schedule C to the IRS.

Note: Contact the IRS to determine corrective action.
___

I’m not taking action because I had no employees for tax year 9999.

4. My Forms W-2, W-2c, W-3, and W-3c are not available for tax year 9999 due to:
___
___
___

Extraordinary Circumstance (e.g., bankruptcy, death, or divorce)
Catastrophe (e.g., fire, flood, or hurricane)
Other: __________________________________________________________
________________________________________________________________
________________________________________________________________

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5. I’m unable to provide Forms W-2, W-2c, W-3, and/or W-3c within the allotted time
because:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. None of the options above covers my situation. My explanation is as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

_________________________________

(

) _________________________

Your Name and Title

Daytime Phone Number

_________________________________
Email
INFORMATION ABOUT THE DATA YOU SEND SSA
The name, Social Security number, and wage amounts on the Forms W-2, W-2c, W-3, and W-3c must be
readable and complete for SSA to correct your employees’ wage records. If they aren’t, prepare readable
copies and submit them. If you need additional Forms W-2, W-2c, W-3, and W-3c, visit
https://www.irs.gov/businesses or call the IRS at 1-800-829-3676. Ensure that all forms show the correct
EIN and tax year for the wages you report.
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
Sections 205(c)(2)(A) and 232 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 result in incorrect payments to beneficiaries due to missing and
discrepant earnings information and in referral of your case to the Internal Revenue Service
(IRS) for penalty assessment purposes.
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We will use the information you provide to properly post employee wages and maintain accurate
earnings records. We may also share your 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 officers and employees of Federal, State or local agencies upon written request in
accordance with the Internal Revenue Code (IRC) U.S.C 6103(l)(7), tax return
information (e.g., information with respect to net earnings from self-employment,
wages, payments of retirement income which have been disclosed to the Social
Security Administration, and business and employment addresses) for purposes of,
and to the extent necessary in, determining an individual’s eligibility for, or the
correct amount of, benefits under certain programs listed in the IRC.

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 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. The employer has an obligation to provide the information in this
information collection request to the Social Security Administration. While respondents are not
required to use this particular information collection tool to provide the information, if they do
not, they must use other means. For example, employers may use our Business Services Online
(OMB Control #0960-0626) to submit W-2(c)/W-3(c) information. We estimate that it will take
about 30 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 212356401.

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