SSA-3885 Government Pension Questionnaire Modernized Claims Syste

Government Pension Questionnaire

MCS Screens for SSA-3885

Government Pension Questionnaire

OMB: 0960-0160

Document [pdf]
Download: pdf | pdf
..
r-lA'{-06-2005 08: 56
OPBP 0 i I) Pa\:jment
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•

[l I-e] COUNTRY

•

[13-C] SPOUSE (YIN)

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410 597 0146

P.02/03

MCS blacks out the field "FILING FOR MEDICARE ONLY, RESTRICTING MONTHL Y BENEFITS" for al! claim
types except Retirement,
When the ADDB screen is entered in establish or update mode, the system will check for the presence of Windfall
Elimination (WEP) data:
•	

IfWEP data exists, the ADDB field, CURRENTLY ENTITLED TO A PENSION NOT COVERED
UNDER SSA, will be prefilled with a "Y" value and the user will not be able to change it.

•	

If no WEP data. exists, the ADDB will show whatever field value is currently stored on the MCS
pending file and the user will be able to change the value,

After the user completed the WEPXIWEPI mini-path, future entries to the ADDB screen will result in the software
checking for WEP data, If all occurrences of WEP data have been deleted, the ADDB field will be set to liN" If there
is still underlying MBR data, the value will be a protected "Y".

FACSIMILE: ADDB - ADDITIONAL BENEFITS
MCS

TRANSFER TO: XXXX

NH

SSSSS

S5SSS~SSS

ADDITIONA~

8ENEFIT~

ilDDB

sssso;

ssss.:;sssss

[1-M)
~C':'IVE

o, s .

NILIT,~RY IRI:5ERVE/NATL

GtlARD SEFiVICE U"IER SEPT 7 1939 (¥ IH1: X

[2-111
t.:ORn~lJ

[J-Ci

1,-J RI'. FOR 5 YP.J-RS OR !1ORE [YIN); x

SPOUSE

(Y/N):X

t s-c:

[4-~J

RECEIVING FR RETIREMENT PENSION/ANNUIT~ (YIN): X
SPOUSE iY/~): X
:6-!1]
[7-Cl
COVERE.D UNDER ~'CREIGN 55;" ('i/1J): X
COUNTRY: XXXXXXXXXX
IF COVEP.ED,
[8-,::J
rs-ci
FILING FOF

FOR~IGN

SSA (YIN):

X

REQUIRES FOREIGN QC'S FOR US FILING

('ill-): Y

:1')-:J

[l1-CJ
£;PCIJSE COVERElJ t:NDER SSA OF orHER COUI~TR\' ('1 INI: x
COUNTRY: xxxxxxxxxx
[12-XJ
[U-C)
:IvILIAIl l':MFVY1EE OF FEDF;RAL GOVT IN JMJ 1983 (Y/NI: X
SPOUSE (Y/NI: X
[:1-~!1

ClS-Cj
vot~

JALOAtl;;SE !NIEF.NEE (y/tJ): X

OF POVlCRTY (YIN1:

r~:.~j
JU1.LH'\' fi)R US FED/Sl"rlTE/LOCAL GOV'I PENGIOll 8.t.SED eN ;\~y WCRK yon PEHOP.MED
WHI,:H WAS NIH COVERED UNCt:ll. SSA (Y/Nl: X

fi'''i::'ii:

CUflRElJTLY r;:~1"ITLED TO 1\ PEnSION sor COVERED UNDER 55A (Y/tl):
[\1:I-C 1

X

IF NO. C'O YOT} F,:xPEcr TO BE ENTITLED TO r; PENSION NOT COVERED U"U:F.P.

S~A

IN rHf; FUTURE; i¥llll;

f"'T-c'"J
U' YES. Sf:OW rtJiURE ENTITLEMENT DATE (MMY'lI: !J999
l2',J:-C~

FILING FOR MEDICARE OSLY, RESTRICTING

NO"reL~

BENEFITS (YIN): x

[a-c]

WILL t1EnrCARE
r;:2-t-!;

~J?PLY;

9

1. YES

2, NO

3. ALREADY E:NROlLED ON 1\!JO'l'liER ';';101

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410 5'37 0146

5/512005
'38>;

P.02

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OPBP

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DIV

P~~ment Policy

4113 597 13146

P.B3/B3

Up to nine occurrences of Offset Data may be entered on each GPOD screen. A maximum of seventy-two (72)
occurrences of Offset Data may be entered for each spouse beneficiary.

DELETING GOVERNMENT PENSION RESULTS DATA
To delete a specific occurrence of Offset Data, enter spaces or delete the entries in [l-C] START, l2-C) STOP, [3-C]


TOTAL MONTHLY PENSION AMOUNT,

l4-C] PRORATED MONTHLY LS ONLY AMOUNT, and [5-Cl WITHHELD AMOUNT. The remaining

occurrences of Offset Data will be re-sorted in ascending chronological order.

To delete every occurrence of Offset Data on a full GPOD screen ([lO-M] \1.0RE OFFSET DETERMINATIONS is a

propagated "Y"), enter spaces Or delete the entries in every field in the table. You cannot delete a GPOD screen in the

path by changing a propa gated "Y" in

[IO-M] MORE OFFSET DETERMINATIONS to "N". The remaining occurrences of Offset Data will be re-sorted in

ascending chronological order.


In MACADE, to delete all of the occurrences of Offset Data from the MBR, enter "Y" in

[7-M] DEtETE ALL OFFSET DATA. When processed to update the result will be the deletion of all monthly

pension offset results data (GP MTHLY group) from the MBR.

To delete Exemption Data, enter spaces or delete the entries in [S-Cl START and

[9-C] REASON for the pension(s) that the exemption no longer applies,


FACSIMILE: GPOD - GOVERNMENT PENSION OFFSET DETERMINATION
(RESULTS INPUT)
:ctm

GOVERNMENT l'ENSIOt, OffSET DE:TE:RI1I!i!;:'.TION

NH SSN: S~S-$S-SSSS
[­ OHSET JATA
[l-':J
f z-c:
::.TART
:')'t:OE'

PIC: 55S

CPOD

SS: sss-SS-SSSS

SSSSS SSSSSSSSSS

CS-Cl
WITHHELD

C'lH'S£T

[3-CJ

l4 -:J

TOTAL MONTHLY

t:RORA'l'ED

~~OlJTHLY

( G-OJ

II.fXCCYrI

Wl1CCYYJ

/lMOUNT

AMOU~T

9939,9

PENSION AMOU~r
9<;)(l099999

LS

33'l39~

~99999999

99999~9

sssssssss

;99999

q'~9999

999999999

~99999999

999999"

S~sssssss

;9~99~

99999~

0:)999999$1

999<;93999

9999999

SSSS:3S~SS

~H:"i'

1\XOrJNT

9= 399','

999999

999999999

SSS3SSSSS

:)Si999~

9999939~9

999999999
299999999

9999999

999999

9999999

$SSS5:~SSS

999993

999~99999

299999393

9999999

999999

I)J9999
g99999

999999999

9S9999999

9999999

99?99;

~~9999

99Sl~El(l99q

999993~H

9999999

5S~SSSSSS

393S:-l~

999999

999999999

(l9999999;

9~99999

SSSl>$SSSS

P-Ml
CEL[I~

(- eX£MPT:ON

n~tA

I?E~~,I')N

ALL OFFSBT DAtA (YIN': P

[e-c)

ID

[:)-CI

(MMCCYYI

TYPf.

ELIGIFlTLItt

START

SSSSSSSS
SSSSSSSS

999999

~

ssssssss

999999

9

SSSS:")!';SSSSSSSSS
SSSSSSSS
ss::;sssss
[lJ-H1
MeRE orFSET DETERMINATIO~S (YIN): P
I?F1 2ELP AVAILABLE

99999~

9

S$S~SS3SSSSSSSS

~~SS::;SS$SSSSSSS

"

••..•

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f'1A\-06-2005

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08:28

~E~SON

TRANSF~R

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File Typeapplication/pdf
File Modified2008-06-13
File Created2008-06-13

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