Modified Benefit Formula Questionnaire

FACSIMILE: WEPI - WINDFALL ELIMINATION PROVISION INPUT

MCS WINDFALL ELIMINATION PROVISION INPUT WEPI

[1-C]

TRANSFER TO: XXXX

Number holder ssn: SSSSSSSSS first name: SSSSS SURNAME: SSSSSSSSSS

[2-M]

*Select PENSION SOURCE: P

1=OPM 2=STATE 3=US GOVERNMENT 4=OTHER 5=FOREIGN

[3-C]

IF STATE SELECTED, SHOW STATE ABBREVIATION (INCLUDES GU,PR,SM,VI,DC): pp

[4-M] [5-M]

*PENSION ELIGIBILITY DATE (MMYY): PPPP *PENSION ENTITLEMENT DATE (MMYY): PPPP

[6-M]

*SELECT HOW PENSION IS PAID: P

1=MONTHLY 2=LUMP SUM 3=BOTH

[7-C]

GROSS MONTHLY PENSION AMOUNT AT CONCURRENT ENTITLEMENT MONTH: PPPP.PP

[8-M] [9-C]

*PENSION AMOUNT PROOF (P/N): P IF APPLICABLE, PENSION END DATE (MMYY): PPPP

[10-M]

*IS THE PENSION BASED ON BOTH COVERED AND NON-COVERED SERVICE MONTHS (Y/N): P

[11-C] [12-C] [13-C]

TOTAL PENSION PERIOD (MMYY) FROM: PPPP TO: PPPP OR TOTAL MONTHS: PPP

[14-C] [15-C] [16-C]

NONCVRD PERIOD AFTER 1956 (MMYY) FROM: PPPP TO: PPPP OR TOTAL MONTHS: PPP

[17-O] [18-D]

MORE (Y/N): X PENSION S OF S