Form SSA-58 Modified Benefit Formula Questionnaire-Employer

Form Approved
OMB No. 0960-0477

Social Security Administration

MODIFIED BENEFIT FORMULA QUESTIONNAIRE - EMPLOYER
Social Security Administration
To Agency/Employer:

Date:

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:
To:

Month

Day

Year

Month

Day

Year

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
To:

Month
Day
Year
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:
for the period.
Amount $
From:
Month

Year

Month

Year

To:
NAME OF PERSON PROVIDING INFORMATION
FORM SSA-58 (08-2014) EF (08-2014)

TELEPHONE NUMBER

See Revised Privacy

Privacy Act Statement
Act Statement and
Revised PRA
Collection and Use of Personal Information

Sections 205(a), 205(c)(2)(A), and 215(7)(A) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to ensure the accuracy of the employee's wage
record and to make a determination of eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may result in the referral of your case to the Internal Revenue Service.
We rarely use the information you supply us for any purpose other than to make a determination regarding
benefits eligibility. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0059, entitled, Earnings Recording and Self-Employment
Income System; 60-0089, entitled, Claims Folders Systems; and, 60-0090, entitled, Master Beneficiary
Record. Additional information about these and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs.
Matching programs compare our records with records kept by other Federal, State or local government
agencies. We use the information from these programs to establish or verify a person's eligibility for
federally funded or administered benefit programs and for repayment of incorrect payments or delinquent
debts under these programs.
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 20 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.
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.

FORM SSA-58 (08-2014) EF (08-2014)