Form Approved
Social Security Administration
OMB No. 0960-0565
EMPLOYER REPORT OF SPECIAL WAGE PAYMENTS
PART I - TO BE COMPLETED BY SSA/EMPLOYER:
PART 2 - TO BE COMPLETED BY EMPLOYER:
Tax Year Employee Name
Employee's SSN
SSA Claim Number
(To be completed by SSA)
Employer
Address
Employees are sometime paid wages in a year subsequent to the year that the wages were earned. The most
common types of payments are accumulated (for prior years) vacation pay or sick pay paid after retirement;
deferred compensation; severance pay (when paid on account of retirement) and bonuses--paid pursuant to a
prior agreement or contract.
Wages which are earned in a year prior to the year they are paid usually do not affect benefits payable under the
Social Security annual earnings test. However, for the Social Security Administration to pay benefits accurately,
these prior year amounts must be reported to us. The above named individual has filed for Social Security
benefits. To ensure that correct Social Security benefits are paid, please complete the information below and
return this form to the Social Security Administration. (Please see reverse side for instructions for the completion
of this form.)
1. Employer Identification Number
(EIN)
2. Retirement date
(MM/DD/YYYY)
3. Date employee last performed services
(MM/DD/YYYY)
If the dates in items 2 and 3 are not the same, please explain the difference.
4. For wages paid to the employee in the "tax year" (see Part I above), enter the amount that
was for services performed prior to the tax year; or was not attributable to services rendered
during the tax year; or was paid on account of retirement:
$
Check the type(s) of wages paid in the tax year but for services performed in a prior year or were paid on account of
retirement.
Vacation Pay
Sick Pay
Severance Pay
Bonus
Deferred Compensation
Other (Explain)
5. Will payments listed in item "4" be made for years after the tax year?
Yes
No
If answered Yes, please show the amounts and years in