Form SSA-150 Modified Benefit Formula Questionnaire

Form Approved
OMB No. 0960-0395

Social Security Administration

MODIFIED BENEFIT FORMULA QUESTIONNAIRE
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

/

/

NAME OF PERSON MAKING STATEMENT (if other than above wage earner or self-employed person)

See Revised Privacy Act Statement Attached
PRIVACY ACT STATEMENT: Your response to this request is voluntary; however, failure to provide all or part of
the requested information could prevent an accurate and timely decision on your claim and could affect your Social
Security benefits. The Social Security Administration uses the information you furnish to determine the effect of
your pension on your Social Security benefit, as provided in section 215 of the Social Security Act (42 U.S.C. 415).
The information on this form may be disclosed by the Social Security Administration to another person or agency
for the following purposes: (1) to assist the Social Security Administration in establishing the right of a beneficiary
to Social Security benefits, (2) to facilitate statistical research and audit activities, necessary to assure the integrity
and improvement of the Social Security programs, and (3) to comply with laws requiring the exchange of
information between Social Security and another agency.
We may also use the information you give us when we match records by computer. Matching programs compare
our records with those of other Federal, State, or local government agencies. Many agencies may use matching
programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to
do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available
in Social Security Offices. If you want to learn more about this, contact any Social Security Office.
A modified benefit formula is used to compute Social Security benefits for persons entitled to both a pension or
annuity based on employment after 1956 not covered by Social Security and a Social Security retirement or
disability insurance benefit. The difference in your Social Security benefit computed under the modified formula,
rather than the regular benefit formula, cannot be greater than one-half the amount of the pension or annuity you
received in the first month you are entitled to both the pension or annuity and the Social Security benefit.
the name and address of the agency or organization from which the pension or annuity is received or is
1. Enter
expected to be received.
NAME

ADDRESS (include ZIP Code)

2. Enter the period(s) of employment upon which your pension or annuity is

FROM: (month, year)

TO: (month, year)

3. Enter the period(s) of employment after 1956 not covered by Social

FROM: (month, year)

TO: (month, year)

based (include both employment covered and not covered by Social
Security, if applicable). If unknown, show "unknown".

Security that is used to determine your pension or annuity. If unknown,
show "unknown".

4. Enter the monthly amount of the pension or annuity you are entitled to before any deductions are made to
provide for a survivor annuity, health insurance, etc.

(if amount is unknown, show "unknown".)

$
$

5.

MONTHLY
a) For the month you first receive a Social Security
retirement or disability benefit.
AMOUNT
OR
(if amount is unknown, show "unknown".)
b) For the month you first receive the pension or annuity,
MONTHLY
if later than the month you first receive a Social Security
AMOUNT
retirement or disability benefit.
If you received a lump sum payment in lieu of a monthly pension or annuity, enter the amount of the payment
and, if known, the specific period of time for which the payment was made. If unknown, show "unknown".

$

(Amount)

for the period from

(Month, Year)

Form SSA-150 (7-2003) EF (07-2003) Destroy Prior Editions

through

(Month, Year)

.

REMARKS: (Use this section for any additional information)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take about 8 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the
nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-0001.
See Revised PRA Attached
IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING BEFORE SIGNING THE FORM

I agree to report promptly to the Social Security Administration if my current pension or annuity ceases
because this may affect the amount of my Social Security benefit. I understand that failure to report
cessation of my pension or annuity could result in a lower Social Security benefit than would otherwise
be payable.

I declare under penalty of perjury that I have examined all the information on this form, and on
any accompanying statements or forms, and it is true and correct to the best of my knowledge.
I understand that anyone who knowingly gives a false or misleading statement about a material
fact in this information, or causes someone else to do so, commits a crime and may be sent to
prison, or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, Day, Year)

SIGN
HERE
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, Rural Route)

TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY

(AREA CODE)

CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X). two
witnesses to the signing who know the individual must sign below, giving their full addresses.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State and ZIP Code)

ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA-150 (7-2003) EF (07-2003)

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Privacy Act Statement
Modified Benefit Formula Questionnaire
Sections 205(a), 205(c)(2), 215, and 233 of the Social Security Act (42 U.S.C.§ § 405,
415, and 433), as amended, authorize us to collect this information. The purpose of
collecting this information is to enable the Social Security Administration (SSA) to
complete the employees claim. Your response is voluntary. However, failure to provide
this requested information may prevent an accurate and timely decision on any claim
filed or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for administration and integrity of Social
Security programs. We may also disclose information to another person or to another
agency in accordance with approved routines uses, which include but are not limited to
the following:
1. To enable a third party on an agency to assist Social Security in establishing
rights to Social Security benefits and coverage.
2. To comply with Federal laws requiring the release of information from Social
Security records ( e.g., to the Government Accountability Office and
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level, and,
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in Computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
are available in System of Records Notice 60-0059 (Earnings Recording and SelfEmployment Income System). This notice, additional information about this form, and
any other information regarding our systems and programs are available on-line at
www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 8
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). Send only comments on our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401.