Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

Social Security Adrninistntion

W B No. 09600470

Refer to:

Date:
Claimant:
sodal Security
Number:
Date of Birth:
Employment Dates:

Dear
We need the information listed below In mnnechion with a Social Security daim. Your prompt reply is appreciated.
To determine entitlement to Social Security benefits, we need to know the first date that
wuid 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 dab.li1s the date the person muld have retired
and received a pension had he or she chosen to do SO.

If you have any questions regarding this request, please contact

AGENCYIEMPLOYER RESPONSE:
1. Date the person first met the eligibility requirements to receive a pension:

NO=

It the dab Is prior to Oecember 1,1977, plea80 omit quertlons 24, den, and return in the
enclosed envelope.

2. Pension amount as of

(month of enbitlement to Soda1 Security)

FORM W

1 6 3

(1

2-20001

Destroy All Prior Edlrlons

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

Pension arnount as of:

(Date)

Pension arnount as of:

(Date)

$

$

Employer
Signature

Area Code and Telephone No.
Tie

Date

PapenvoMPrivacy Act Notice: This report is authorized by 20 CFR 404.408a.While your response is voluntary, your
cooperation is needed to assist us in determining the correct amount of Social Security benefits payable to the
person named above.
Please See Revised PRA, Attached

PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
53507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required t o answer
these questions unless we display a valid Office of Management and 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.

'U.S. Government Pr~nttngOffice- 2001

- 472-692120571

The following revised PRA Statement will be inserted 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.
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.