Form SSA-58 Modified Benefit Formula Questionnaire-Employer

See Revised Privacy Act Statement
See Revised PRA Statement

SSA will insert the following revised PRA Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Title 20 CFR 404.702 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to assure that a person’s wage record is
accurate and make a correct determination of eligibility for Social Security benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from assuring that a person’s wage record is accurate and prevent us
from making a correct determination of eligibility for Social Security benefits.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing eligibility benefits. 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 (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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 Systems of Records
Notices entitled, Earnings Recording and Self-Employment Income System, 60-0059 and Master
Beneficiary Record, 60-0090. These notices, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.

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 20
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.