Modified Benefit Formula Questionnaire

(12-2024)
(12-2024)

MODIFIED BENEFIT FORMULA QUESTIONNAIRE

4. Enter pension begin month.
5. Enter pension end month, if pension entitlement
ended in the past.
6.

7.

Form SSA-150 (12-2024)

Page 2 of 2
Important Information: Read the Following Carefully

I agree to report promptly to the Social Security Administration if my current pension or annuity ceases because this may affect
the amount of my Social Security benefit. I understand that failure to report cessation of my pension or annuity could result in a
lower Social Security benefit than would otherwise be payable.
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.
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, Rural Route)

DATE (MMIDD/YYYY)
TELEPHONE NUMBER AT WHICH YOU MAY
BECONTACTED DURING THE DAY
(
(AREA
CODE)

CITY AND STATE

ZIP CODE

Privacy Act Statement
Collection and Use of Personal Information

Section 215 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 delay our determination and could affect the amount of your
claim for benefits.
We will use the information to determine your eligibility for benefits. We may also share your information for the following

purposes, called routine uses:

• To third party contacts (e.g., employers and private pension plan) in situations where the party to be contacted has, or
is expected to have, information relating to the individual's capability to manage his/her affairs or his/her eligibility for,
or entitlement to, benefits under the Social Security program; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security
Administration (SSA) in the efficient administration of its programs. We will disclose information under the routine use
only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in
accomplishing an agency function relating to this system of records.
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 Notice (SORN) 60-0090, entitled Master
Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006, at 71FR 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 Statement
This information collection meets the requirements of 44U.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 control
number. We estimate that it will take about 8 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.soccialsecuritygov Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-300-772-1213 (TTY 1-800-325-0778). You may send
comments regarding this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.