Form SSA-3885 Government Pension Questionnaire

Form Approved
OMB No. 0960-0160

SOCIAL SECURITY ADMINISTRATION

GOVERNMENT PENSION QUESTIONNAIRE
NAME OF WAGE EARNER OF SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (If other than wage earner or
self-employed person)

RELATIONSHIP TO WAGE EARNER
OR SELF-EMPLOYED PERSON

Privacy Act Statement Collection and Use of Personal Information
Section 202 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you
provide to determine 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 prevent an accurate and timely decision on your claim and
could affect your Social Security benefit. We rarely use the information you supply for any purpose other than making a
determination relating to the effect 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 Notices entitled Claims Folders Systems,
60-0089, and Master Beneficiary Record, 60-0090. Additional information about these and other system of records notices and
our programs is 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. See Revised Privacy Act Statement Attached
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.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 12.5 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.socialsecurity.gov. Offices are
also listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
1. Enter the name and address of the agency or organization below from which your government pension or annuity is received:
NAME OF AGENCY OR ORGANIZATION ADDRESS OF AGENCY OR ORGANIZATION PHONE NUMBER OF
AGENCY OR ORGANIZATION
(Include area code)
2. (a) Enter the last day of employment upon which your pension or annuity is based.
State

Federal

u

MONTH

YEAR

Local

(b) On the date shown in (a) above, was this employment covered under Social Security for
u
benefit purposes?
3. (a) What was the first month for which you began receiving your pension or annuity?
(b) Could you have been eligible for and received this pension or annuity earlier had you
stopped working and made application? (If yes, answer (c).)
(c) When could you have first received this pension/annuity?
4. (a) Did you elect FERS or another covered plan?
If yes, when?
5. (a) Do you receive your pension/annuity weekly, biweekly, or monthly?

Yes
MONTH

If yes, what is the amount of the annuity before reduction for the lump sum?

No
YEAR

u

Yes

u

MONTH

u

Yes

u

MONTH

u

No
YEAR
No
YEAR

u

What is the current pension amount after any deductions made to provide for a survivor
$
annuity, but before any deductions for health insurance, allotments, bonds, etc.?
(b) Did you elect a lump sum payment with a reduced annuity?
u
Form SSA-3885 (10-2014) EF (10-2014)
Destroy Prior Editions

DAY

$

Yes

No

5. (c) Did you elect an annuity in one lump sum payment?
If yes, what is the amount?

Yes

No

Yes

No

u $

What was the specific period of time for which the lump sum payment was made?
(d) Has your pension amount changed for any months for which you are applying or have
u
been receiving spouse's or surviving spouse's Social Security benefits?
If yes, give the former amount(s) and dates(s) of change below:
FORMER AMOUNT(S)
$
$
$

DATE(S) OF CHANGE
MONTH
YEAR

If the date in either 3(a) or 3(c) is before 7/1/83, answer item 6.

6. (a) Were you receiving at least one half support from your spouse at the time your spouse
became entitled to retirement or disability insurance benefits (or stopped work prior to
u
disability), or if you are a widow or widower at the time your spouse died?
(b) Have you filed proof of such support with the Social Security Administration?

u

Yes

No

(If yes, answer (b).)
Yes

No

REMARKS

IMPORTANT INFORMATION - PLEASE READ THE FOLLOWING CAREFULLY AND THEN SIGN BELOW
I agree to promptly report to the Social Security Administration if the amount of my present pension or annuity
changes. I understand that my pension or annuity may affect my Social Security benefits and that failure to report such pension
or annuity may result in an overpayment which I may have to pay back.
I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable under
Federal law by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)

DATE (Month, Day, Year)

MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, Rural Route)

Telephone number(s) at WHICH YOU
MAY BE CONTACTED DURING THE
DAY (Include Area Code)

CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full address.
SIGNATURE OF WITNESS
SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State and ZIP Code)

Form SSA-3885 (10-2014) EF (10-2014)

ADDRESS (Number and Street, City, State and ZIP Code)