Form SSA-L2765 Request for Self-Employment Information

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Form Approved

OMB No. 0960-0508

Social Security Administration
Retirement, Survivors, and Disability Insurance
Request for Self-Employment 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 about self-employment earnings reported to us by the
Internal Revenue Service. Please complete the information on the back of this

letter and return it to us promptly.

We cannot put these earnings on your Social

Security record until the name and Social Security number reported agree with our
records.
Name:
Social Security Number:
Reported Net Earnings from Self-Employment:
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 the Schedule SE of your tax return and
your Social Security card.
3. If the name and number shown on the Social Security card:
- Agree exactly with the information shown above, contact your local Social
Security office. Do not mail this letter back to us.
- Do not agree with the information shown above, fill in the requested
information on the back of this letter. Then mail this letter to us in the
enclosed envelope.

4. Make sure that your future tax returns have your correct name and Social
Security number.

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.
Please See Reverse
Form SSA-L2765-C1

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REQUEST FOR SELF-EMPLOYMENT INFORMATION
1. Name shown On your Social Security card:

First

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

Last

M.I.

2. Social Security number on your card:

3. Were the earnings shown on the front of this letter reported on your (joint/individual) tax
return?

If No, explain

If Yes, do the earnings reported belong to:
Spouse's Name:

First

You

Your spouse (Please check one)

D

Last

M.I.

Spouse's SSN:
4. Have you ever used another name?

No

II

First

M.I.

First

M.I.

Yes

(Give other names used)

Last

II

Last

5. Daytime phone number where you can be reached

.

If you have any questions, you may call us toll-free at 1-800-772-1213. We can answer
most questions over the phone. You can also write or visit any Social Security office.
If you do call or visit an office, please have this letter with you. The office that
serves your area is located at:

Social Security- ddmitibVudion
Enclosure:
Envelope
See Next Page

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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 Red.ir.tinn

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.