Form SSA-3885 Government Pension Questionnaire

Form SSA-3885 (XX-XXXX) UF
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Social Security Administration

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OMB No. 0960-0160

Government Pension Questionnaire
Name of Wage Earner or Self-Employed Person

Social Security Number

Name of Person Making Statement (If other than wage earner or self-employed person)

Relationship to Wage Earner or
Self-Employed Person

1.

Enter the name and address of the agency or organization below from which your government pension or annuity is received:
Name of Agency or Organization
Address of Agency or Organization
Phone Number of Agency
or Organization (Include
area code)

2.

(a) Enter the last day of employment upon which your pension or annuity is based.
State

Federal

Month

Local

(b) On the date shown in (a) above, was this employment covered under Social Security
for benefit purposes?
3.

Yes
Month

(a) What was the first month for which you began receiving your pension or annuity?
(b) Could you have been eligible for and received this pension or annuity earlier had you
stopped working and made an application? (If yes, answer (c).)

Yes
Month

(c) When could you have first received this pension/annuity?
4.

Yes

(a) Did you elect FERS or another covered plan?

Month

If yes, when?
5.

Year

Day

No
Year

No
Year
No
Year

(a) Do you receive your pension/annuity weekly, biweekly, or monthly?
What is the current pension amount after any deductions made to provide for a survivor
$
annuity, but before any deductions for health insurance, allotments, bonds, etc.?
(b) Did you elect a lump sum payment with a reduced annuity?
If yes, what is the amount of the annuity before reduction for the lump sum?

No

Yes

No

Yes

No

$

(c) Did you elect an annuity in one lump sum payment?
If yes, what is the amount?

Yes

$

What was the specific period of time for which the lump sum payment was made?
(d) Has your pension amount changed for any months for which you are applying or have
been receiving spouse's or surviving spouse's Social Security benefits?
If yes, give the former amount(s) and date(s) of change below:
Former Amount(s)
$
$
$

Date(s) of Change
Month

Year

Form SSA-3885 (XX-XXXX) UF

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If the date in either 3(a) or 3(c) is before 7/1/83, answer item 6.

6.

(a) Were you receiving at least one half support from your spouse at the time your spouse
became entitled to retirement or disability insurance benefits (or stopped work prior to
disability), or if you are a widow or widower at the time your spouse died?

Yes

No

(If yes, answer (b).)

(b) Have you filed proof of such support with the Social Security Administration?

Yes

No

Remarks

Important Information - Please Read the Following Carefully
I agree to promptly report to the Social Security Administration if the amount of my present pension or annuity changes. I
understand that my pension or annuity may affect my Social Security benefits and that failure to report such pension or annuity
may result in an overpayment which I may have to pay back.
Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or
continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain
any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
Date (MM/DD/YYYY)

Telephone number(s) at which you may be contacted during the
day (Include area code)

Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route)

City and State

ZIP Code

Form SSA-3885 (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Section 202(k) 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 prevent an accurate and timely
decision on any claim filed.
We will use the information you provide to determine benefit eligibility. We may also share the information for the
following purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the efficient
administration of our programs; and,

•

To student volunteers, individuals working under a personal services contract, and other workers who
technically do not have the status of Federal employees, when they are performing work for us, as authorized
by law, and they need access to personally identifiable information (PII) in our records in order to perform their
assigned agency functions.

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 Notices (SORN) 60-0089, entitled
Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422; and SORN
60-0090, Master Beneficiary Record, as published in the 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.

Paperwork Reduction Act
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 13 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of
this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.