MONTHLY
AMOUNT
Form SSA-150 (10-2014) EF (10-2014)
Social Security Administration
Form Approved
OMB No. 0960-0395
MODIFIED BENEFIT FORMULA QUESTIONNAIRE
SOCIAL SECURITY NUMBER
NAME OF PERSON MAKING STATEMENT (if other than above wage earner or self-employed person)
Privacy Act Statement
Collection and Use of Personal Information
Section 215 of the Social Security Act, as amended, allows us to collect this information. We will use the information you provide
to make a determination on the effect of your pension on your Social Security benefit. Furnishing us this information is voluntary.
However, failing to provide us with all or part of the information may not allow us to make a correct determination regarding your
claim and could affect your Social Security benefit. We rarely use the information you supply for any purpose other than for of
your pension on your Social Security benefit. However, we may use the information for the administration of our programs
including sharing information: 1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and, 2. To facilitate statistical research, audit, or
investigative activities necessary to assure the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us). A complete list of when we may share your information with others, called routine uses,
is available in our Privacy Act System of Records Notice 60-0090, entitled, Master Beneficiary Record. Additional information
about this and other system of records notices and our programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security office. We may share the information you provide to other health agencies
through computer matching programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a person's eligibility for federally
funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.
A modified benefit formula is used to compute Social Security benefits for persons entitled to both a pension or annuity
based on employment after 1956 not covered by Social Security and a Social Security retirement or disability insurance
benefit. The difference in your Social Security benefit computed under the modified formula, rather than the regular
benefit formula, cannot be greater than one-half the amount of the pension or annuity you received in the first month
you are entitled to both the pension or annuity and the Social Security benefit.
1. Enter the name and address of the agency or organization from which the pension or annuity is received or is expected to be
received.
ADDRESS (include ZIP Code)
2. Enter the period(s) of employment upon which your pension or
annuity is based (include both employment covered and not
covered by Social Security, if applicable). If unknown,
show "unknown".
FROM:(month,year) TO:(month,year)
3. Enter the period(s) of employment after 1956 not covered by Social
Security that is used to determine your pension or annuity. If
unknown, show "unknown".
FROM:(month,year) TO:(month,year)
4. Enter the monthly amount of the pension or annuity you are entitled to before any deductions are made to provide for a
survivor annuity, health insurance, etc.
a) For the month you first receive a Social Security
retirement or disability benefit.
MONTHLY
AMOUNT
(if amount is unknown, show "unknown".)
b) For the month you first receive the pension or annuity,
if later than the month you first receive a Social
Security retirement or disability benefit.
5. If you received a lump sum payment in lieu of a monthly pension or annuity, enter the amount of the payment
and, if known, the specific period of time for which the payment was made. If unknown, show "unknown".
for the period from
(Month, Year)
through
(Month, Year)
OR
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON
NAME
(if amount is unknown, show "unknown".)
(Amount)