Form SSA-3885 Government Pension Questionnaire

Form Approved
OMB No. 0960-0160

SOCIAL SECURITY ADMINISTRATION

GOVERNMENT PENSION QUESTIONNAIRE
NAME OF WAGE EARNER OF SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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

RELATIONSHIP TO WAGE EARNER OR
SELF-EMPLOYED PERSON

Privacy Act Statement
Government Pension Questionnaire - Section 202 of the Social Security Act (42 U.S.C. § 402), as amended, authorizes us to collect this information. The information you
provide will be used to determine the effect of your pension on your Social Security benefit. The information you furnish on this form is voluntary. However, failure to provide
the requested information could prevent an accurate and timely decision on your claim and could affect your Social Security benefit. We rarely use the information you
supply for any purpose other than for making a determination relating to the effect of your pension on your Social Security benefit. 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, Claims Folders Systems, 60-0089 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.
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
12.5 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 1- 800-325-0778). You may send comments on our time estimate above
to: SSA, 6401Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

See Revised Privacy Act Statement Attached

1.

Enter the name and address of the agency or organization below from which your government pension or annuity is received:
NAME OF AGENCY OR ORGANIZATION

2.

ADDRESS OF AGENCY OR ORGANIZATION

(a) Enter the last day of employment upon which your pension or annuity is
based.

State

Federal

4.

(a) What was the first month for which you began receiving
your pension or annuity?

DAY

YEAR

X

Yes

X

MONTH

No
YEAR

X

(b) Could you have been eligible for and received this pension or annuity
earlier had you stopped working and made application? (If yes, answer
(c).)
(c) When could you have first received this pension/annuity?

X
X

(a) Did you elect FERS or another covered plan?

X

If yes, when?
5.

MONTH

Local

(b) On the date shown in (a) above, was this employment covered under
Social Security for benefit purposes?
3.

PHONE NUMBER OF AGENCY
OR ORGANIZATION
(Include area code)

Yes
MONTH

Yes
MONTH

X

No
YEAR

No
YEAR

(a) Do you receive your pension/annuity weekly, biweekly, or monthly?
What is the current pension amount after any deductions made to provide for a survivor annuity, but
$
before any deductions for health insurance, allotments, bonds, etc.?

(b) Did you elect a lump sum payment with a reduced annuity?
If yes, what is the amount of the annuity before reduction
for the lump sum?

X

(c) Did you elect an annuity in one lump sum payment?

X

If yes, what is the amount?

No

Yes

No

$

$

What was the specific period of time for which the lump sum payment was made?
Form SSA-3885 (07-2011) EF (07-2011) Destroy Prior Editions

Yes

5.

(d) Has your pension amount changed for any months for
which you are applying or have been receiving spouse's or
surviving spouse's Social Security benefits?
If yes, give the former amount(s) and dates(s) of change below:

Yes

No

X
DATE(S) OF CHANGE

FORMER AMOUNT(S)

MONTH

YEAR

$
$
$

6.

If the date in either 3(a) or 3(c) is before 7/1/83, answer item 6.
(a) Were you receiving at least one half support from your
Yes
No
spouse at the time your spouse became entitled to
retirement or disability insurance benefits (or stopped work
prior to disability), or if you are a widow or widower at the
(If yes, answer (b).)
time your spouse died?
X
(b) Have you filed proof of such support with the Social
Security Administration?

Yes

X

No

REMARKS

IMPORTANT INFORMATION - PLEASE READ THE FOLLOWING CAREFULLY AND THEN SIGN BELOW

I agree to promptly report to the Social Security Administration if the amount of my present pension or annuity changes. I
understand that my pension or annuity may affect my Social Security benefits and that failure to report such pension or annuity may
result in an overpayment which I may have to pay back.
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application
or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, Day, Year)

MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, Rural Route)

Telephone number(s) at WHICH YOU MAY BE
CONTACTED DURING THE DAY

SIGN
HERE

X

(

)
(Area Code)

CITY AND STATE

ZIP 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 and ZIP Code)

ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA-3885 (07-2011) EF (07-2011)

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 202 of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to determine the effect of your pension on your Social
Security benefit.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on your claim and could affect your
Social Security benefit.
We rarely use the information you supply for any purpose other than making a determination
relating to the effect of your pension on your Social Security benefit. 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 assure
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 entitled Claims Folders Systems, 600089, and Master Beneficiary Record, 60-0090. Additional information about these and other
system of records notices and our programs is available from our Internet website 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.