Form SSA-58 Modified Benefit Formula Questionnaire-Employer

Form Approved
OMB No. 0960-0477
Social Security Administration
MODIFIED BENEFIT FORMULA QUESTIONNAIRE- EMPLOYER
Revised
Privacy
Act
PRIVACY ACT: This report is authorized by law 20 CFRSee
404.702.
While
your response
is
Statement
voluntary, your cooperation is needed to assure that the person's
wage record is accurate and that
a correct determination of eligibility for Social Security benefits is made.
PAPERWORK REDUCTION ACT STATEMENT: 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 and Budget control number. We estimate that
it will
take you
about 20
See
Revised
PRA
minutes to read the instructions, gather the necessary facts, and answer the questions.
COMPUTER MATCHING: 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.
Social Security Administration
Date: _____________
To Agency/Employer: _______________________
Claimant:__________________________________ Social Security Number________________
We need this information in connection with a claim for Social Security Benefits. Please respond
by________________________
If you have any questions about this request, please contact: _____________________________
1. Indicate the first month and year for which _______________________ could have received a
pension from your organization, even though this may not be the actual retirement date.
Month__________________________ Year________________________
If the above date is before January 1986, do not answer the remaining questions.
______________________________________________________________________________
2. The period(s) of employment on which the pension is based are:
From: Month_____________ Day___________ Year_______________
To:

Month_____________ Day___________ Year _______________

_____________________________________________________________________________
3. The period(s) of employment after 1956 not covered by Social Security used to determine the
amount of the pension are:
From: Month______________ Day_______________ Year _________________
To:
Month______________ Day _______________ Year ___________________
______________________________________________________________________________
4. Indicate the amount of the pension before any deductions are made to provide for a survivor
annuity, health insurance, etc. as of ____________________________
Amount $ _____________________
______________________________________________________________________
5. If a lump sum was paid in lieu of a monthly pension, enter the amount of the payment and the
specific period of time for which the payment was made:
Amount $ _______________ for the period.
From: Month_______________ Year_______________
To:

Month _______________Year _______________

SIGNATURE NAME AND TITLE OF PERSON PROVIDING INFORMATION TELEPHONE NUMBER

Form SSA-58 (11-1998) EF (05-2002)

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
Sections 205(a), 205(c)(2)(A), and 215(7)(A) of the Social Security Act, as amended, authorize
us to collect this information. We will use the information you provide to ensure the accuracy of
the employee’s wage record and to make a determination of eligibility for Social Security
benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may result in the referral of your case to the Internal Revenue Service.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0059, entitled, Earnings Recording
and Self-Employment Income System; 60-0089, entitled, Claims Folders Systems; and, 60-0090,
entitled, Master Beneficiary Record. Additional information about these and other system of
records notices and our programs are available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

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 (OMB) control number. We estimate that it will take about
20 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.