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

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.

To verify past wages:

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

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  Check the “Prior Wages” line; and

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

To verify BWE/IRWE:

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

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

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  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.

To verify cafeteria plan deductions:

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

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

To verify current wage information:

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

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  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 they cannot provide the information needed to estimate future wages as required by SI 00820.150.

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

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

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

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