Government Pension Questionnaire

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: XXXXXXXXXXXX
X 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