Social Security Administration
Statement Concerning Your Employment in a Job
Not Covered by Social Security
EMPLOYEE NAME:
EMPLOYEE ID #:
EMPLOYER NAME:
ALVIN COMMUNITY COLLEGE
EMPLOYER ID#:
74-1405330
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled,
you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from
Social Security based on either your own work or the work of your husband or wife, or former husband or wife,
your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however,
will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may
be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400 = $100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication,
“Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at www.socialsecurity.gov
. You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of
the Windfall Elimination Provision and the Government Pension Offset Provision on my potential
future Social Security Benefits.
E-MAIL ADDRESS:
DATE:
Form SSA-1945 (01-2013 ACC Rev 10-2014)
Information about Social Security Form SSA-1945
Statement Concerning Your Employment in a Job Not Covered by Social Security
New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State
and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not
covered under Social Security. The statement explains how a pension from that job could affect future Social
Security benefits to which they may become entitled.
Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the
document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential
effects of two provisions in the Social Security law for workers who also receive a pension based on their work in
a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s
Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social
Security benefit received as a spouse, surviving spouse, or an ex-spouse.
Employers must:
Give the statement to the employee prior to the start of employment;
Get the employee’s signature on the form; and
Submit a copy of the signed form to the pension paying agency.
Social Security will not be setting any additional guidelines for the use of this form.
Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf
.
Paper copies can be requested by email at ofsm.oswm.rqct.orders@ssa.gov
or by fax at 410-965-2037. The request must
include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also,
if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of
25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (01-2013 ACC Rev 10-2014)