Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

See below for
revised Privacy Act
and Paperwork
Reduction Act
Statements.

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 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

Privacy Act Statement

Collection and Use of Personal Information

Sections 202-205, 223, 226, 228, 1611, 1631, 1818, 1836, and 1840 (42 U.S.C. §§ 402405, 423, 426, 428, 1382, 1383, 1395i-2, 1395o, and 1395s) and Title VIII of the Social
Security Act, as amended, authorize us to collect this information. We will use the
information you provide on this form to determine the claimant’s entitlement to Social
Security benefits.
Completion of this form is voluntary; however, your cooperation is needed to assist us in
determining the correct amount of Social Security benefits payable to the claimant named
above.
We rarely use this information you supply for any purpose other than for determining
continuing eligibility. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
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 comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by 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.
A complete list of routine uses for this information is available in our System of Records
Notice entitled, Claims Folders Systems (60-0089). The notice, additional information
regarding this form, routine uses of information, and our programs and systems is
available on-line at www.socialsecurity.gov or at your local Social Security office.