SSA-95-SM (No Record Questionnaire second request) (current)

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Date: MM/DD/YYYY

Form Approved
OMB No. 0960-0432
SECOND REQUEST
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.

999999999-99-MMDDYY

SSA-95-SM (03-17)

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3. ( ) I filed Forms W-2 under EIN __________ , rather than the EIN shown above. Attach legible
copies if on paper. Enter the Wage File ID (WFID) if electronic (or other proof of filing if a thirdparty, such as a payroll service e-filed for you).
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 p.m., Eastern Time.

999999999-99-MMDDYY

SSA-95-SM (03-17)

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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, authorizes us to collect this information. We
will use the information you provide to properly credit the employee’s earnings record.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may result in the referral of your case to the Internal Revenue Service.
We rarely use the information you supply us for any purpose other than to reconcile discrepancies from
IRS and SSA employer-reported wages. However, we may use the information for the administration of
our programs including sharing information:
1.
To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2.
To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notice 60-0059, entitled, Earnings Recording and Self-Employment
Income System. Additional information about this and other system of records notices and our programs
is available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or local
government agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.

999999999-99-MMDDYY

SSA-95-SM (03-17)

See Revised PRA
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Statement
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.

999999999-99-MMDDYY

SSA-95-SM (03-17)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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 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 referral of your case to the Internal Revenue Service for penalty
assessment purposes.
We will use the information to properly post employee wages and maintain accurate earnings
records. We may also share your information for the following purposes, called routine uses:
•

To State audit agencies for auditing State supplementation payments and Medicaid
eligibility considerations; and

•

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, 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.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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
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 21235-6401.