Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

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. 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 (09-2013)
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.
_____________________________________________________________________________________
Name of Individual Completing Form Title
Date

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 3 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 21235-0001.

See Revised PRA
Statement Attached

FORM SSA-L4163 (09-2013)
Destroy Prior Editions

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 3
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.