SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

Form SSA-L4163 (11-2017)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0470

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: $ ________________________________

Form SSA-L4163 (11-2017)

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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 Number

_______________________________________ ________________________________
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 Security
Blvd, Baltimore, MD 21235-6401.

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