Form SSA-308 Modified Benefit Formula Questionnaire--Foreign Pension

Form Approved
OMB No. 0960-0561

Social Security Administration

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

U.S. SOCIAL SECURITY NUMBER

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

PRIVACY ACT: 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.
See Revised Privacy Act Statement Attached
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.
See Revised PRA Attached

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 10 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING 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, 6401 Security Blvd., Baltimore,
MD 21235-6401.
A modified benefit formula is used to compute U.S. Social Security benefits for persons entitled to both a pension or annuity based
on employment after 1956 not covered by U.S. Social Security (including a government or private pension or annuity based on
employment or self-employment, (employment meaning work) in another country) and a U.S. Social Security retirement or disability
insurance benefit. The difference in your U.S. 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 U S. Social Security benefit. See revised paragraph #4 attached
NAME

1.

Enter the name and address of the agency or organization from
ADDRESS (Include postal code)
which you received or expect to receive the pension. If you receive
more than one pension, complete a separate form for each pension.

YES

If "yes", submit evidence such as an award
certificate or letter from the agency paying
the pension, ignore the rest of the form, and
sign your name on the last page in the
appropriate space.

NO

If "no", complete the rest of the form and
sign it.

Is the pension listed in item 1 a partial benefit paid under a U.S.
Social Security {Totalization} agreement?

2.

Is the pension listed in item 1 based on a totalization agreement
(combined credits) with the United States?

UNKNOWN If "unknown," contact the agency
paying the pension for further
information about the pension, complete
the form and sign it.
FROM: (month, day, year)

3.

Enter the entire period(s) of employment or self-employment upon
which your pension is based. Provide specific dates. Enter a "?" if
TO: (month, day, year)
some information is unknown.

4.

Enter only the period(s) of employment or self-employment from item
3 above used to determine your pension which was after 1956 and
which was not covered by U.S. Social Security. Provide specific TO: (month, day, year)
dates. Enter a "?" if some information is unknown.

FROM: (month, day, year)

From SSA-308 (11-2006) EF (11-2006)

FROM: (month, day, year)

5.

Enter specific periods of voluntary contributions or other
non-employment based credits included in the computation of
your pension. Enter a "?" if some information is unknown.

6.

Enter the date you first became (or expect to become) eligible
for the pension.

7.

TO: (month, day, year)

DATE: (month, day, year)

Enter the amount of your pension before any deductions are made to provide for a survivor annuity, health
insurance, etc. (if the pension is not paid in U.S. dollars, show the amount of the pension in the currency in
which it is paid.)
a) for the month you first receive a U.S. Social Security
benefit.
Amount
OR
b) for the month you first receive the pension, if later than
the month you first receive a U.S. Social Security
benefit.
Amount
If the pension is paid on other than a monthly basis,
indicate how often it is paid.

Weekly

Bi-Weekly

Other

If the amount of the pension is unknown, show
"unknown."

8.

If you received a lump sum payment instead of a periodic pension, enter the amount of the payment and, if
known, the specific period of time for which the payment would be due. If unknown, show "unknown."
$

for the period from
(Amount)

through
(Month, Year)

(Month, Year or Lifetime)

Remarks:

IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING BEFORE SIGNING THE FORM
I agree to report promptly to the U.S. Social Security Administration if my current pension or annuity ceases because this may affect the amount of
my U.S. Social Security benefit. I understand that failure to report cessation of my pension or annuity could result in a lower U.S. Social Security
benefit than would otherwise be payable. I also agree to report promptly to the U.S. Social Security Administration if I become entitled to another
pension or annuity from any country or foreign employer after the cessation of the pension or annuity I currently receive or expect to receive.
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

CITY AND STATE (or Country)

ZIP CODE OR POSTAL CODE

(Area 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 address.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State, Country and ZIP Code/Postal Code)

ADDRESS (Number and Street, City, State, Country and ZIP Code/Postal Code)

From SSA-308 (11-2006) EF (11-2006)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 215 of the Social Security Act, as amended, authorizes us to collect the information on this form.
The information you provide will be used to determine the effect of your pension on your Social Security
benefits. Your response is voluntary. However, failure to provide the 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 determining the amount
of the Social Security benefit you are entitled to receive. However, in accordance with 5 U.S.C. § 552a(b) of
the Privacy Act, we may disclose the information provided on this form (1) to enable a third party or an
agency to assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to make
determinations for eligibility in similar health and income maintenance programs at the Federal, state and
local level; (3) to comply with Federal laws requiring the disclosure of the information from our records; and
(4) to facilitate statistical research, audit or investigative activities necessary to assure the integrity of SSA
programs.
We may also use the information you provide when we match records by computer. Computer matching
programs compare our records with those of 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 or
administered benefit programs and for repayment of payments or delinquent debts under these programs.
The law allows us to do this even if you do not agree to it.
A complete list of routine uses for this information is contained in our System of Records Notice 60-0089
(Claims Folders System). Additional information regarding this form and our other system of records
notices and Social Security programs are available from our Internet website at www.socialsecurity.gov or at
your local Social Security office.

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 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. To find the nearest office call 1-800-772-1213 (TTY 1-800-325-0778). Send
only comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.

SSA will substitute the following revised Paragraph #4 upon approval of
the revisions:
U.S Social Security retirement or disability benefits may be determined using a
different formula under the Windfall Elimination Provisions (WEP), when you
also receive a pension based on employment or self-employment, (employment,
meaning work) from a foreign pension not covered by U.S. Social Security.
Social Security benefit amounts use only earnings covered under Social Security
with a benefit formula that gives proportionately higher amounts to workers with
low lifetime earnings. A worker with a substantial period of non-covered work
during their lifetime appears to have lower lifetime earnings than they actually
had. WEP reduces the primary insurance amount upon which benefits are based
and affects all benefits paid on that record except survivors. The difference in
U.S. Social Security benefits computed under WEP cannot be greater than onehalf the amount of the non-covered pension received in the first month you are
entitled to both the non-covered pension and the U.S. Social Security benefit.