Modified Benefit Formula Questionnaire - Foreign Pension

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a) and (c), and 215(a)(7) and (d)(3) of the Social Security Act, as amended, allow
us to collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent an accurate and timely decision on any claim
filed or could result in the loss of benefits.
We will use the information to determine the effect of your foreign pension on your Social
Security benefits. We may also share your information for the following purposes, called routine
uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to the individual’s capability to manage his or her affairs or his
or her eligibility for or entitlement to benefits under the Social Security program when
the data are needed to establish the validity of evidence or to verify the accuracy of
information presented by the individual, and it concerns the amount of his or her benefit
payment; and
2. To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
SSA in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees.
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 Notices
(SORN) 60-0089, entitled Claims Folders Systems, and 60-0090, entitled Master Beneficiary
Record. Additional information and a full listing of all our SORNs are available on our website
at www.ssa.gov/privacy/sorn.html.