Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

Form Approved
OMB No. 0960-0470

Social Security Administration
Refer to:
•

Date:
Claimant: ________________________________
Social Security
Number: _________________________________
Date of Birth: _____________________________
Employment Dates: ________________________

Dear _______________________________________ :
We need the information listed below in connection with a Social Security claim. Your prompt reply is
appreciated.
To determine entitlement to Social Security benefits, we need to know the first date that
_____________________ could have received a pension from your organization. In some cases, we also
need to know the amount of the pension.
The pension eligibility date may or may not be the actual retirement date. If it is the date the person could
have retired and received a pension had he or she chosen to do so.
If you have any questions regarding this request, please contact
____________________________ at ___________________________________.
_____________________________________________________________________________________
AGENCY/EMPLOYER RESPONSE:
1. Date the person first met the eligibility requirements to receive a pension:
_____________________________
NOTE: If the date is prior to December 1, 1977, please omit questions 2-3, sign, and return in the
enclosed envelope.
2. Pension amount as of
______________________________________________________________________
(month of entitlement to Social Security)
$ _____________________
(amount)
(over)

FORM SSA-L4163 (12-2000)
Destroy All Prior Editions

3. Please show any pension increases and dates of increases after the date shown in question 2.
Pension amount as of:

___________ $ _______________
(Date)
Pension amount as of:
___________ $ _______________
(Date)
_____________________________________________________________________________________
Employer
Area Code and Telephone No.
_____________________________________________________________________________________
Signature Name of Individual Completing Form
Title
Date

Paperwork/Privacy Act Notice: This report is authorized by 20 CFR 404.408a. While your response is
voluntary, your cooperation is need to assist us in determining the correct amount of Social Security
Removing Privacy Act Statement
benefits payable to the person named above.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44
U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to
answer these questions unless we display a valid Office of Management Budget control number. We
estimate that it will take you about 3 minutes to read the instructions, gather the necessary facts, and
answer the questions.

See below for revised Paperwork Reduction Act Statement
*U.S. Government Printing Office: 2001 – 472-69220571

FORM SSA-L4163 (12-2000)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 3
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). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to our time
estimate to this address, not the completed form.