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Letter To Employer Requesting Wage Information

Download and Print the SSA-L4201

Request may not be processed if the form is incomplete or illegible.

Important Information - Form Approved OMB No. 0960-0138

Office Address:

Telephone Number:

FAX Number:

Office Hours:          Date:

We are asking for your help in obtaining wage information about the employee named on the attached pages. Please complete sections 1 through 3 of the form if they are indicated, and section 5 in all cases.

If you prefer to send a payroll printout instead of completing the form, please include an explanation of the items on the printout.

For your convenience, we are enclosing a postage-paid reply envelope. If a fax number is shown above, you may instead fax the information to that number.

We appreciate your help in this matter. If you have any questions, please call the telephone number above and ask for .

Enclosure(s) Stamped Reply Envelope

Field Office Manager

And much more...