TN 48 (11-08)

A. When To Use SSA-L4201-BK

Use the SSA-L4201-BK to:

• verify past wage information (including blind work expenses (BWE), impairment-related work expenses (IRWE), cafeteria plan deductions, and child support deductions, when needed) when you cannot obtain the information by other means (see SI 00820.130), or

• obtain current wage information to estimate future wages when you cannot establish an estimate otherwise (see SI 00820.150).

B. Procedure

1. General

Completion of this form by the employer is voluntary. Always include a postage-paid return envelope with the form.

2. Reference Number

Complete the “REFERENCE NUMBER” line with a number or code of your choice, when the worker is not the SSI beneficiary. DO NOT use the beneficiary’s name or Social Security number as a REFERENCE NUMBER fill-in. The fill-in should permit association of the worker’s wage information with the corresponding beneficiary’s file.

3. Verifying Past Wages

To verify past wages:

• Fill in the employee name and SSN on the response sheets;

• Check the “Prior Wages” line; and

• Indicate the years and months for which wage amounts are needed.

4. Verifying BWE/IRWE

To verify BWE/IRWE:

• Check the “Prior Wages” line, and label the “OTHER” columns on the form with the type of BWE or IRWE you want to verify.

• Do not use “BWE” or “IRWE” as a label, since neither term would have any meaning to an employer.

• Draw a line through these columns if no information is needed.

Examples of alternate labels include “Union Dues” “FICA” and “Income Taxes” for BWE and “Payroll Deduction/Loan for Wheelchair Purchase” for IRWE.

5. Verifying Cafeteria Plan Deductions

To verify cafeteria plan deductions:

• Check the “Deductions From Gross Wages” line and the “Prior Wages” line, and

• Check the years and months on the following pages for which the information is needed.

6. Obtaining Current Wage Information

To verify current wage information:

• Fill in the employee name and SSN on the response sheets, and

• Check the “Current Wages” line.

REMINDER: Do not routinely request current wage information when requesting past wage information. Request current wage information only if there is reason to doubt the individual's allegation or he or she cannot provide the information needed to estimate future wages as required by SI 00820.150.

7. Verifying Termination of Employment

To verify termination of employment, check the “Current Wages” line.

8. Verifying Child Support Garnishment Deductions for the Deemor Wage-Earner

To verify child support garnishment deductions for the deemor wage-earner:

• Check the “Deductions from Gross Wages” line and the “Prior Wages: line.

• Check the years and months on the following pages for which the information is needed.

C. References

• GN00301.285, Statements and Other Documentation,

• GN 00301.286, Evidence Documentation and Retention

• GN 00301.288, What Information is Needed on EVID and DROC in PE Situations to Identify the Type of Evidence Submitted.

• SI 00601.100D, Form SSA-8510, Authorization for the Social Security Administration to Obtain Personal Information

• SI 00820.102, Cafeteria plans.

• SI 00820.130, Evidence of Wages or Termination of Wages

• SI 00820.135, Wage Verification - Over $65 Per Month

• SI 00820.550C., Verification of BWE.

• SI 00820.550C. and DI 10520.030B., Verification of IRWE.

• SI 00830.420 and SI 01320.145, Child support and deeming.

D. Exhibit

To view the Form SSA-L4201–BK, go to SSA-L4201–BK .