SSA-4163 (current version)

Form Approved
OMB No. 0960-0470

Social Security Administration
Refer to:
•

Date:
Claimant: ________________________________
Social Security
Number: _________________________________
Date of Birth: _____________________________
Employment Dates: ________________________
Dear _______________________________________ :
We need the information listed below in connection with a Social Security claim. Your prompt reply is appreciated.
To determine entitlement to Social Security benefits, we need to know the first date that _____________________
could 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 date. If it is the date the person could have retired
and received a pension had he or she chosen to do so.
If you have any questions regarding this request, please contact
____________________________ at ___________________________________.
________________________________________________________________________________________________
AGENCY/EMPLOYER RESPONSE:
1. Date the person first met the eligibility requirements to receive a pension: _____________________________
NOTE: If the date is prior to December 1, 1977, please omit questions 2-3, sign, and return in the
enclosed envelope.
2. Pension amount as of ______________________________________________________________________
(month of entitlement to Social Security)
$ _____________________
(amount)

(over)

FORM SSA-L4163 (12-2000)
Destroy All Prior Editions

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

___________ $ _______________
(Date)

Pension amount as of:

___________ $ _______________
(Date)

________________________________________________________________________________________________
Employer
Area Code and Telephone No.
________________________________________________________________________________________________
Signature
Title
Date
________________________________________________________________________________________________
Paperwork/Privacy Act Notice: This report is authorized by 20 CFR 404.408a. While your response is voluntary, your
cooperation is need to assist us in determining the correct amount of Social Security benefits payable to the
person named above.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer
these questions unless we display a valid Office of Management 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 Printing Office: 2001 – 472-69220571

FORM SSA-L4163 (12-2000)