Basic (07-14)

RM 02226.010 Instructions for Completing Form SSA-4130

A. Policy on the Form SSA-4130

The Division of Earnings and Business Services (DEBS) will use the instructions in this section to complete the individual fields on the Form SSA-4130 (Interoffice Itemized Adjustments).

B. Instructions for completing Form SSA-4130

Use the following chart to fill-in the appropriate field on the Form SSA-4130:

NOTE: To view a facsimile of Form SSA-4130, see RM 02226.005C.

Field …

How to Complete …

Number of pages:

  • One page report, enter 1 of 1;

  • Multi-pages report, enter number of the page and the last page number of the report on each page and enter T– (last page number) in red, in upper left hand corner of form.

NOTE: Multi-page could represent more than one Form SSA-4130 or attached forms or listings.

Types of Modification (TOM):

Check the types of modification block, that the adjustment represents:

  • Block 06-08 – adjustments are all increases;

  • Block 09-11 – adjustments are all decreases;

  • Block 12-14 – adjustments are mixed;

  • Block 16 – adjustments cancel a Form 941C, 94X, 3964 or 4668;

  • Block 17 – adjustments transfer earnings to the Suspense File.

Microprints or Microfilm:

Check appropriate block:

  • Microprints attached; or

  • Microfilm required.

Report Film Reference:

Complete if required:

  • Entered to reference source of items corrected;

  • Entered if items are to be data entered from microprints or microfilm (must check the Microprints or Microfilm field);

  • Enter the following, if annual report:

  • First six digits of Microfilm Report Number (ECN);

  • Five-digit sequence of first item to be keyed (From SEQ);

  • Five-digit sequence of last item to be keyed (To SEQ).

Employer Name

Enter employer’s name

Annual, Qrtly, Mixed or Sensitive Report:

 

Identify type of reporting periods for items to be keyed:

  • If all items are annual, check “Annual” block;

  • If all items are quarterly, check “Quarterly” block;

  • If items are both (annual and quarterly), check mixed block;

  • If adjustment is, classified “Sensitive,” check Sensitive Report (show entry in red).

NOTE: The 800# Employer Reporting Specialist is the only one authorized to complete the Sensitive Report field.

EIN

Enter Employer Identification Number.

ESTAB/PRU

Establishment Number/Payroll Record Unit:

Complete as required:

  • If establishment number, transcribe the related establishment code (4 positions or less);

  • If State or local Payroll Record Unit (PRU), transcribe the related PRU (3 positions).

NOTE: Include Coverage Group, if applicable (A 1 or 2 in front of PRU).

  • If Type of Modification 17, enter “SWED”;

  • If military employment and related EIN is one that reports more than one type of employment, enter “mil” as required;

NOTE: Employment code must be “M.”

  • If earnings are for non-active duty training (weekend duty after 1987) under a Military Reserve EIN, the field must reflect “WWWW.”

NOTE: Employment code must be blank.

Employment Code

A-H-L-M-Q (R-S):

Enter employment code as follows:

  • Agriculture, transcribe “A”;

  • Household, transcribe “H”;

  • Limitation of Liability (state and local), transcribe “L”;

  • Military, transcribe “M”;

  • Medicare Qualified Government Employment (MQGE), transcribe “Q”;

  • Railroad – Non-FICA, transcribe “R”;

  • State FICA, transcribe “S”;

  • Other - leave blank.

GT Items:

Enter total number of items keyed for entire adjustment report.

NOTE: For multi-page, enter only on first page.

Total Net Differences:

In the “Wages,” “Tips,” & “Medicare” fields, enter total net difference, on first page, if:

  • Multi-page report (enter N/A on subsequent pages);

  • Microprints attached;

  • To be keyed from Microfilm.

NOTE: If total net difference is negative, check “CR” indicator.

SSN

Enter Social Security Number (9 digits) for each item to be listed.

NOTE: If no SSN, enter all zeroes (000-00-0000).

Initials (1st and 2nd )

Enter initials of each individual; if no initial, leave blank.

Employee Last Name

Enter last name of each individual: If no last name exists, then enter “None” in the Last Name field.

NOTE: If items are from attachments, enter “See attached.”

Period

Enter reporting period for each item. Enter the last two digits of the year only for an annual item.

Wages, Tips & Medicare Decrease/Increase

Enter amount of Wage adjustment:

  • If adjustment is a decrease, enter amount in “wages decrease” field;

  • If adjustment is an increase, enter amount in “wages increase” field;

  • Enter total, in respective “total” field.

NOTE: When using type of modification (TOM) code 12-14, show all decreases on one line and all increases on the next line for the same SSN.

Enter amount of Tips adjustment:

  • If adjustment is a decrease, enter amount in “tips decrease” field;

  • If adjustment is an increase, enter amount in “tips increase” field;

  • Enter total of all items in the “total block” for each field.

NOTE: When using TOM code 12-14, show all decreases on one line and all increases on the next line for the same SSN.

Enter amount of Medicare adjustment:

  • If adjustment is a decrease, enter amount in “Medicare decrease” field;

  • If adjustment is an increase, enter amount in “Medicare increase” field;

  • Enter total for all items listed in “total block” for each field.

NOTE: When using TOM code 12-14, show all decreases on one line and all increases on the next line for the same SSN.

Column Total

Enter the Column Total for each column listed.

Net Difference This Page

Enter the net difference between “wages decrease” and “wages increase” fields for the page:

  • If both fields contain earnings, determine the Net difference between the fields;

  • If only one field contains earnings, enter the field total;

  • Check the “CR” indicator, if the total represents a negative amount.

NOTE: This represents the employer earnings total for single page forms.

Enter the net difference between “tips decrease” and “tips increase” fields for the page.

  • If both the “tips decrease” and “tips increase” fields contain earnings, determine the net difference between the fields;

  • If only one field contains earnings, enter the field total. Total is the net difference;

  • Check the “CR” indicator, if the total represents a negative amount.

NOTE: This represents the employer earnings total for single page form.

Enter the net difference between “Medicare decrease” and “Medicare increase” fields for the page.

  • If both “Medicare decrease” and “Medicare increase” fields contain earnings, determine the net difference between the fields;

  • If only one field contains earnings, enter the field total. Total is the net difference;

  • Check the “CR” indicator, if the total represents a negative amount.

NOTE: This represents the employer earnings total for single page form.

Authority For This Adjustment:

NOTE: This is a mandatory field.

Enter “authority for this adjustment”:

  • If appropriate, check the block that reflects the authority;

  • If not, enter reason in the “Other” field; and

  • Show type of workload investigated in the beginning of authorization statement (i.e., RECON, 6494, etc.).

Examples of authorization statements:

  • Family Employment;

  • Items offset in error;

  • EE in suspense with incorrect wages;

  • Claims investigation.

NOTE: For all “non-suspense” related adjustments, annotate (in red ink) “ICOR/RCOR exception” in addition to any other explanation.

PPD By and Date: (Prepared By)

Enter the clerk first initial and last name and the current date in the appropriate field (e.g., J. Doe and MM/DD/YY).

Location:

Enter the Division, Branch and Unit Number (DBS/BSB-I/Unit XX).

Authorizer

The Manager or the Management Support Specialist (MSS) should enter their signature.

C. Procedure for handling completed Forms SSA-4130 (Interoffice Itemized Adjustments)

After preparing the Form SSA-4130, forward it to the Wilkes-Barre Direct Operations Center (WBDOC) for processing.

NOTE: DBS should handle sensitive reports in accordance with the current internal operation instructions.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0102226010
RM 02226.010 - Instructions for Completing Form SSA-4130 - 08/23/2016
Batch run: 05/07/2018
Rev:08/23/2016