OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Modified Benefit Formula Questionnaire-Employer

OMB 0960-0477 ยท SSA.

OMB 0960-0477

SSA collects information on Form SSA-58 to verify the claimant's allegations on Form SSA-150 (OMB#0960-0395, Modified Benefits Formula Questionnaire). SSA uses the SSA-58 to determine if the modified benefit formula is applicable and when to apply it to a person's benefits. SSA sends Form SSA-58 to an employer for pension-related information, if the claimant is unable to provide it. The respondents are employers of people who are eligible after 1985 for both Social Security benefits and a pension based on work not covered by SSA.

The latest form for Modified Benefit Formula Questionnaire-Employer expires 2027-07-31 and is listed under ICR 202004-0960-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form SSA-58 Modified Benefit Formula Questionnaire-EmployerForm
Supporting Statement -0960- 0477 (Final).docxSupporting Statement A
Supporting Statement - 0477.docxSupporting Statement A
Addendum 0477.docxSupplementary Document
Addendum 0477.docx Supplementary Document
Modified Benefit Formula Questionnaire-Employer Form
Modified Benefit Formula Questionnaire-Employer Other-Privacy Act Statement (revised)

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202004-0960-003 Revision of a currently approved collection 2020-08-07
201701-0960-016 Revision of a currently approved collection 2017-05-17 Approved without change
201311-0960-008 Revision of a currently approved collection 2014-03-10 Approved without change
201011-0960-003 Revision of a currently approved collection 2010-12-30 Approved without change
200802-0960-005 Extension without change of a currently approved collection 2008-02-19 Approved without change
200501-0960-005 Extension without change of a currently approved collection 2005-01-24 Approved without change
200112-0960-010 Extension without change of a currently approved collection 2001-12-17 Approved without change
199811-0960-004 Extension without change of a currently approved collection 1998-11-18 Approved without change
199511-0960-005 Extension without change of a currently approved collection 1995-11-05 Approved without change
199208-0960-006 Revision of a currently approved collection 1992-08-31 Approved without change
198906-0960-011 New collection (Request for a new OMB Control Number) 1989-06-19 Approved without change