Government Pension Questionnaire

MCS Additional Benefits (ADDB)

The Additional Benefits (ADDB) screen records information about a claimant’s and his/her current or prior spouse's potential or actual entitlement to benefits from other sources.

FACSIMILE:  ADDB - ADDITIONAL BENEFITS

MCS      ADDITIONAL BENEFITS             ADDB

NH SSSSSSSSS    SSSSS    SSSSSSSSSS    CL SSSSSSSSS    SSSSS   SSSSSSSSSS

[1-M]

ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939 (Y/N): X

[2-M]                                                   [3-C]

WORKED IN RR FOR 5 YEARS OR MORE (Y/N): X               SPOUSE (Y/N): X

[4-M]                                                 [5-C]

RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X      SPOUSE (Y/N): X

[6-M]                                     [7-C]

COVERED UNDER FOREIGN SSA (Y/N): X        COUNTRY: XXXXXXXXXX IF COVERED

[8-C]                                    [9-C]

FILING FOR FOREIGN SSA (Y/N): X    REQUIRES FOREIGN QC'S FOR US FILING (Y/N): X

[10-C]                                                  [11-C]

SPOUSE COVERED UNDER SSA OF OTHER COUNTRY (Y/N): X      COUNTRY: XXXXXXXXXX

[12-M]                                                      [13-C]

CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X      SPOUSE (Y/N): X

[14-M]                                   [15-C]

JAPANESE INTERNEE (Y/N): X               VOW OF POVERTY (Y/N):

 [16-M]

QUALIFY FOR US FED/STATE/LOCAL GOVT PENSION BASED ON ANY WORK YOU PERFORMED WHICH WAS NOT COVERED UNDER SSA (Y/N): x

[17-M]

CURRENTLY ENTITLED TO A PENSION NOT COVERED UNDER SSA (Y/N): X

[18-C]

IF NO, DO YOU EXPECT TO BE ENTITLED TO A PENSION NOT COVERED UNDER SSA IN THE FUTURE (Y/N): X

[19-C]

IF YES, SHOW FUTURE ENTITLEMENT DATE (MMYY): 9999

Government Pension Data Collection

The Government Pension (GPI1) screen is used to enter information regarding the government pension of the claimant.

FACSIMILE: GPI1 - GOVERNMENT PENSION

COMM                 GOVERNMENT PENSION                   GPI1

SS: SSS-SS-SSSS SSSSS SSSSSSSSSS

[1-M]

*GOVERNMENT PENSION IDENTIFICATION NUMBER: XXXXXXXXXXXXXXX

 [2-M]

*ENTER GOVERNMENT PENSION TYPE: 9

   1=FEDERAL 2=STATE 3=LOCAL 4=MILITARY.

 [3-M]

*IS THIS GOVERNMENT PENSION BASED ON ANOTHER PERSON'S EARNINGS (Y/N): X

[4-M]                              

*IS THIS GOVERNMENT PENSION BASED ONLY ON EMPLOYMENT COVERED UNDER SS (Y/N): X

[5-C]                                                         [6-C]

EARLIEST DATE ELIGIBLE FOR THIS PENSION (MMDDCCYY): 99999999 PROOF (Y/N): X

[7-C]                                [8-C]

PERIODIC PAYMENTS AWARDED (Y/N): X   LUMP SUM PAYMENT AWARDED (Y/N): X

The Government Pension-Address (GPI2) screen is used to enter government employer and government pension payer information.

FACSIMILE GOVERNMENT PENSION-ADDRESS

COMM GOVERNMENT PENSION-ADDRESS     GPI2

SS: SSS-SS-SSSS    SSSSS SSSSSSSSSSS

PENSION IDENTIFICATION NUMBER: SSSSSSSSSSSSSSS PENSION TYPE: SSSSSSSS

[1-O]

EMPLOYER NAME:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[2-O]

ADDRESS 1:  XXXXXXXXXXXXXXXXXXXXXX         ADDRESS 2:  XXXXXXXXXXXXXXXXXXXXXX

ADDRESS 3:  XXXXXXXXXXXXXXXXXXXXXX         ADDRESS 4:  XXXXXXXXXXXXXXXXXXXXXX

     [3-O]                                     [4-C]         [5-O]

     CITY:  XXXXXXXXXXXXXXXXXXXXXX             STATE:  XX    ZIP:  99999

  [6-O]                                       [7-C]                 [8-O]

  CONTACT:  XXXXXXXXXXXXXXXXXXXXXXXXXX        PHONE:  XXXXXXXXXXXXX EXTENSION:  9999

   [9-O]                                         [10-O]

 E-MAIL:  XXXXXXXXXXXXXXXXXXXXXXXXXXXX         FAX:  XXXXXXXXXXXX

 [11-O]

 PAYER NAME:  XXXXXXXXXXXXXXXXXXXXXXXXXXX

[12-O]

ADDRESS 1:  XXXXXXXXXXXXXXXXXXXXXX         ADDRESS 2:  XXXXXXXXXXXXXXXXXXXXXX

ADDRESS 3:  XXXXXXXXXXXXXXXXXXXXXX         ADDRESS 4:  XXXXXXXXXXXXXXXXXXXXXX

 [13-O]                                    [14-C]         [15-O]

 CITY:  XXXXXXXXXXXXXXXXXXXXXX            STATE : XX     ZIP: 99999

  [16-O]                                       [17-C]                [18-O]

 CONTACT:  XXXXXXXXXXXXXXXXXXXXXXXXXXXX      PHONE :  XXXXXXXXXXXX EXTENSION:  9999

 [19-O]                                        [20-O]

 E-MAIL:  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX      FAX :  XXXXXXXXXXXX

[21-O]                        [22-O]

PAYER PLAN STATE: XX          PAYER PLAN NAME: XXXXXXXXXX

The Government Pension Lump Sum (GPLS) screen is used to enter information about a pension payment made in a lump sum.

FACSIMILE:  GPLS - GOVERNMENT PENSION LUMP SUM

COMM                   GOVERNMENT PENSION LUMP SUM                    GPLS

SS: SSS-SS-SSSS   SSSSS SSSSSSSSSS

PENSION IDENTIFICATION NUMBER: SSSSSSSSSSSSSSS PENSION TYPE: SSSSSSSS

 [1-M]

*GOVERNMENT PENSION LUMP SUM AMOUNT: 9999999999

[2-M]

*GOVERNMENT PENSION LUMP SUM AWARD DATE (MMDDCCYY): 99999999

[3-C]

LUMP SUM START DATE, IF SPECIFIED ON AWARD (MMDDCCYY): 99999999

 [4-C]

 LUMP SUM STOP DATE, IF SPECIFIED ON AWARD (MMDDCCYY): 99999999

[5-C]

LUMP SUM MONTHLY PRORATION AMOUNT, IF SPECIFIED ON AWARD: 999999999

[6-C]

FOR ALTERNATIVE ANNUITY, INITIAL MONTHLY PENSION AMOUNT: 999999999

 [7-C]

 INITIAL MONTHLY PENSION AMOUNT IF LUMP SUM NOT PAID: 999999999

The Government Pension Periodic Payments (GPP1) screen is used to enter information about government pension periodic payments.

FACSIMILE: GPP1 - GOVERNMENT PENSION PERIODIC PAYMENTS

COMM           GOVERNMENT PENSION PERIODIC PAYMENTS           GPP1

SS: SSS-SS-SSSS   SSSSS SSSSSSSSSS

PENSION IDENTIFICATION NUMBER: SSSSSSSSSSSSSSS  PENSION TYPE: SSSSSSSS  

  [1-M]              [2-O]              [3-M]         [4-M]

[*START (MMDDCCYY)  STOP (MMDDCCYY)    *AMOUNT       *FREQUENCY

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

| 99999999           99999999           9999999999    X

 [5-O]

 NEXT EXPECTED PENSION INCREASE DATE (MMCCYY): 999999