Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form (Page 4 of 7) in pdf

Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form Page 4

Page 4 of 7

Date: MM/DD/YYYY

Form Approved

OMB No. 0960-0432

EMPLOYER QUESTIONNAIRE

SSA HAS NO RECORD OF EMPLOYER REPORT

The IRS records show that you paid 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 (Form 1040) electronic and/or paper returns) for

Tax Year: YYYY

EIN: 99-9999999

Employer Name: Employer Name

Employee Soc. Security Wage Totals:

$999,999.00

Employee Soc. Security Tip Totals:

$999,999.00

Employee Medicare Wage/Tip Totals:

$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):

( ) Enclosing the original Copy A of paper Forms W-2 and W-3, or

( ) Sending SSA an electronic file.

Caution: You must identify this as a reconciliation file when you submit it! Enclose the

electronic receipt showing the Wage File ID (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):

( ) Enclosing legible copies of paper Forms W-2 and W-3, or

( ) Sending SSA an electronic file.

999999999-99-MMDDYY

SSA-95-SM (04-11)

Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form Page 4