Wage Reports and Pension Information

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Social Security Administration
Potential Private Retirement Benefit Information
Social Security Number:
Name:

We are writing to tell you that you, or the worker whose Social Security number
appears at the top of this form, MAY be entitled to some retirement benefits from a
private employer. Also, your family, or the worker's family, may be entitled to
retirement or survivor benefits.
These Are Not Social Security Benefits
These potential benefits are NOT Social Security benefits. We do not make any
decisions about the payment of these benefits. Please see below for basic
information about these retirement benefits.
Information About Retirement Benefits
You have, or the worker has, earned retirement benefits although no longer employed
in a job covered by the retirement plan. These are called "deferred vested benefits."
Private retirement plan administrators must provide information about such benefits
to us through the Internal Revenue Service. We provide this reported information about
the retirement plan when the individual asks for it or when a claim is filed for Social
Security benefits. Social Security does not have any information about the benefits
other than what appears below.
If You Want to Apply for These Benefits
If you want to apply for these retirement benefits or have any questions, you should
contact the Plan Administrator shown below. The Plan Administrator
provided the information as of the date in the "Year Reported" field below. If
you or the worker has already filed a claim and received payment from the plan
below, you may not be eligible for any additional benefits. Include a copy of
this notice when you contact the Plan Administrator.
Plan Name

Plan Number

Identification Number

Plan Administrator and Address

Year Reported

Estimated Amount

Type of Benefit

Payment Frequency

Units or Shares

Value of Account

IMPORTANT: See the other side of this page for an explanation of this information.
For SSA Use Only:
Form SSA-L99-C1 (03-20) Destroy prior editions

EXPLANATION OF INFORMATION
YEAR
REPORTED

This is the year for which the Plan Administrator reported
retirement plan information to the Internal Revenue
Service.

ESTIMATED
AMOUNT

This was the amount that would be paid under the plan then
in effect. The actual amount could differ. If you have
already received payments from the plan, the amount shown
on this notice should be disregarded.

TYPE OF
BENEFIT

The code listed identifies the type of annuity to be paid:

PAYMENT
FREQUENCY

The code listed shows how often the estimated payments
would be made under the plan:
A Lump Sum
E Monthly
B
M Other (Payment frequency
Annually
C
not reported)
Semi-Annually
D Quarterly

UNITS OR
SHARES

If the retirement amount is based on units or shares the
number of units or shares will be shown. The number of
shares will be shown followed by "S."

VALUE OF
ACCOUNT

If shown, this indicates the value of the account at the time
the worker stopped working under the plan or at the time the Plan
Administrator reported the information.

A
B
C
D
E
F
G
M

A single payment of a lump sum
Annuity payable over a fixed number of years
Life annuity
Life annuity with period certain
Cash refund life annuity
Modified cash refund life annuity
Joint and last survivor annuity
Other (Type of annuity not reported)

QUESTIONS OR If you have questions, you should contact the Plan Administrator.
If you cannot locate the Plan Administrator, contact your
COMPLAINTS
former employer. If you cannot locate your former employer,
check the reference department of your local library or
contact your State's corporation commission. This agency
should be in the State Government section of the telephone
directory.

The U.S. Department of Labor's Employee Benefits Security
Administration (EBSA) administers certain provisions of the
Employee Retirement Income Security Act of 1974 (ERISA)
and may be of assistance in locating your plan administrator,
or if you have a complaint about the way the private
retirement plan has handled your claim. More information
about your rights under ERISA is available at:
https://www.dol.gov/privatebenefitinfo
You may also contact an EBSA Benefits Advisor at 1(866)444-3272.

Form SSA-L99-C1 (03-20)(Back)