Modified Benefit Formula Questionnaire

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Section 215 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may delay our determination and could affect the amount of your claim for benefits.

We will use the information to determine your eligibility for benefits. We may also share your information for the following purposes, called routine uses:

• To third party contacts (e.g., employers and private pension plan) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his/her affairs or his/her eligibility for, or entitlement to, benefits under the Social Security program; and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration SSA in the efficient administration of its programs. We will disclose information under the routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0090, entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy/.