Social Security Administration Please read the back of the last copy before you complete this form. Form Approved OMB No. 0960-0527 Name (Claimant) (Print or Type) Social Security Number Wage Earner (If Different) Social Security Number Part I APPOINTMENT OF REPRESENTATIVE I appoint this person, ,
LOST WAGE CLAIMS . Who may be eligible for Lost Wage Claim Reimbursements: 1. An innocent victim of violent crime who either physically or mentally is unable to return
What type of wage theft are you alleging? Note: you may not file a claim for expenses. Please provide all requested information. 1. What type of back wages are you owed?
3867 12/2016) Tips For Claim Submission • An eligible dependent is defined as a spouse, qualifying child, or qualifying relative. • A qualifying child is defined as a tax dependent child up to age
Attention: You may file Forms W-2 and W-3 electronically on the SSA’s Employer W-2 Filing Instructions and Information web page, which is also accessible