SSA-150

MODIFIED BENEFIT FORMULA QUESTIONNAIRE

Download and Print the SSA-150

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (if other than above wage earner or self-employed person)
PRIVACY ACT STATEMENT:

Your response to this request is voluntary; however, failure to provide all or part of the requested information could prevent an accurate and timely decision on your claim and could affect your Social Security benefits.

The Social Security Administration uses the information you furnish to determine the effect of your pension on your Social Security benefit, as provided in section 215 of the Social Security Act (42 U.S.C. 415).

The information on this form may be disclosed by the Social Security Administration to another person or agency for the following purposes:

(1) to assist the Social Security Administration in establishing the right of a beneficiary to Social Security benefits,

(2) to facilitate statistical research and audit activities, necessary to assure the integrity and improvement of the Social Security programs, and

(3) to comply with laws requiring the exchange of information between Social Security and another agency.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government.

The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices.

If you want to learn more about this, contact any Social Security Office.
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