Ssa-3885

Form Approved
OMB No. 0960-01 60

SOCIAL SECURITY ADMINISTRATION

GOVERNRllENT PENSION QUESTIONNAIRE
NAME OF WAGE EARNER OF SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

RELATIONSHIP TO WAGE EARNER OR
SELF-EMPLOYED PERSON

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PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS: Your response to this request is voluntary; however, failure to provide all or part of the
information could prevent an accurate and timely decision on this claim and could affect your Social Security benefit. The Social Security Administration uses the
information you furnish to determine the effect of your worker's compensation or other public disability benefit on your Social Security disability insurance benefit,
as provided in section 224 of the Social Security Act (42 U.S.C.424). 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, 121 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 the Social Security Administration 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.
These and other reasons why information about you may be used or given out are explained in the Federal Register. If you want t o learn more about this, contact
any Social Security office.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of
the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid
OMB control number. We estimate that it will take you about 12.5 minutes to complete this form. This includes the time it will take to read the instructions, gather
the necessary facts and fill out the form.

1 . l ~ n t e the
r name and address of the agency or organization below from which your government pension or annuity is
received:

2.

1

IPHONE

IADDRESSOF AGENCY OR ORGANIZATION

NAME OF AGENCY OR ORGANIZATION

NUMBER OF AGENCY
OR ORGANIZATION
(Include area code)

DAY

(a) Enter the last day of employment upon which your pension or annuity is
based.

i-J state

Federal

(b) On the date shown in (a) above, was this employment covered under
Social Security for benefit purposes?

3.

YEAR

No
YEAR
MONTH
-

(a) What was the first month for which you began receiving
your pension or annuity?
(b) Could you have been eligible for and received this pension or annuity
earlier had you stopped working and made application? (If yes, answer

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4.

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(a) Did you elect FERS or another covered plan?

YEAR

MONTH

(c) When could you have first received this pensionlannuity?-

• yes

b

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MONTH

If yes, when?

No
YEAR

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5. (a) Do you receive your pensionlannuity weekly, biweekly, or monthly?

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-

What is the current pension amount after any deductions made t o provide for a survivor annuity, but
$
before any deductions for health insurance, allotments, bonds, etc.?
(b) Did you elect a lump sum payment with a reduced annuity?
If yes, what is the amount of the annuity before reduction
for the lump sum?
(C) Did you elect an annuity in one lump sum payment?

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If yes, what is the amount?

yes

No

i-J y e s

No

$

$

What was the specific period of time for which the lump sum payment was made?
Form SSA-3885 (8-1999)

EF (9-2000) Destroy Prior Editions

5. (d) Has your pension amount changed for any months for
which you are applying or have been receiving spouse's or
surviving spouse's Social Security benefits?
If yes, give the former amount(s) and date&)

Yes

No

c

of change below:
DATE(S1 OF CHANGE

FORMER AMOUNTIS)

MONTH

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YEAR

I f the date in either 3(a) or 3(c) is before 711183, answer item 6.

6. (a) Were you receiving at least one half support from your
spouse at the time your spouse became entitled t o
retirement or disability insurance benefits (or stopped work
prior t o disability), or if you are a widow or widower at the
time your spouse died?

yes

No

(If yes, answer (b1.1
c

(b) Have you filed proof of such support with the Social
Security Administration?

No

REMARKS

IMPORTANT INFORMATION-PLEASE READ THE FOLLOWING CAREFULLY AND THEN SIGN BELOW

I agree t o promptly report t o the Social Security Administration if the amount of m y present pension or annuity changes. I
understand that my pension or annuity may affect m y Social Security benefits and that failure t o report such pension or
annuity may result in an overpayment which I may have t o pay back.

.

I know that anyone who makes or causes t o be made a false statement or representation o f material fact in an application or
for use in determining a right to,payment under the Social Security A c t commits a crime punishable under Federal law by fine,
imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
DATE (Month, Day, Year)

SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

HERE

Telephone nurnber(s)at WHICH YOU MAY BE

MAILING ADDRESS (Number and Street, Apt. No., P. 0.Box, Rural Route)

CONTACTED DURING THE DAY

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(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 (XI, t w o witnesses t o
the signing who know the individual must sign below, giving their full address.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

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

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

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Form SSA-3885 (8-1999)

EF (9-2000) Destroy Prior Editions