Form SSA-150 Modified Benefit Formula Questionnaire

(12-2024)

MODIFIED BENEFIT FORMULA QUESTIONNAIRE
(Complete this form only if you received a non-covered pension prior to January 2024)

4. Enter the date you became eligible for a non-covered
pension.
5. Enter the pension entitlement start and end date
(if pension entitlement ended in the past) for a non-covered
pension.
6.

7.

MM/YYYY
From: (MM/YYYY) To: (MM/YYYY)

(12-2024)