SSA-58 (current)

Form Approved
OMB No. 0960-0477

Social Security Administration

MODIFIED BENEFIT FORMULA QUESTIONNAIRE- EMPLOYER
PRIVACY ACT: This report is authorized by law 20 CFR 404.702. While your response is voluntary, your cooperation is
needed to assure that the person's wage record is accurate and that a correct determination of eligibility for Social Security
benefits is made.
PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 20 minutes
to read the instructions, gather the necessary facts, and answer the questions.
COMPUTER MATCHING: 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.
Social Security Administration
Date:
To Agency/Employer:
Claimant:

Social Security Number

We need this information in connection with a claim for Social Security Benefits. Please respond by
If you have any questions about this request, please contact:
1. Indicate the first month and year for which
could have received a pension from your organization, even though this may not be the actual retirement date.
Month

Year

If the above date is before January 1986, do not answer the remaining questions.
2. The period(s) of employment on which the pension is based are:
From:
Month

Day

Year

Month

Day

Year

To:
3. The period(s) of employment after 1956 not covered by Social Security used to determine the amount of the pension are:
From:
Month

Day

Year

Month

Day

Year

To:

4. Indicate the amount of the pension before any deductions are made to provide for a survivor annuity, health insurance,
etc. as of
Amount $
5. If a lump sum was paid in lieu of a monthly pension, enter the amount of the payment and the specific period of time for
which the payment was made:
Amount $
for the period.
From:
Month

Year

Month

Year

To:

SIGNATURE AND TITLE OF PERSON PROVIDING INFORMATION

Form SSA-58 (11-1998) EF (05-2002)

TELEPHONE NUMBER