Modified Benefit Formula Questionnaire

SSA will insert the following revised PRA Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Section 215 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may not allow us to make a determination on your claim and could affect your Social Security benefit.

We will use the information to make a determination on the effect of your pension on your Social Security benefit. We may also share your information for the following purposes, called routine uses:

1. To third party contacts that may have information relevant to the Social Security Administration's establishment or verification of information provided by representative payees or payee applicants; and

2. To the Department of the Treasury for collecting Social Security taxes or as otherwise pertinent to tax and benefit payment provisions of the Social Security Act (including Social Security number verification services); investigating the alleged theft, forgery, or unlawful negotiation of Social Security checks; determining the Federal tax liability on Social Security benefits pursuant to 26 U.S.C. 6050F, as amended by Pub. L. 98-21. The information disclosed will consist of the following: the aggregate amount of Social Security benefits paid with respect to any individual during any calendar year; the aggregate amount of Social Security benefits repaid by such individual during such calendar year; the aggregate reductions under section 224 of the Social Security Act in benefits which would otherwise have been paid to such individual during the calendar year on account of amounts received under a worker's compensation act; and the name and address of such individual; depositing the tax withheld on benefits paid to nonresident aliens in the Treasury (Social Security Trust Funds) pursuant to 26 U.S.C. 871, as amended by Pub. L. 98-21.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.