Modified Benefit Formula Questionnaire

FACSIMILE: WEPI - RECOMP RETRIEVAL WINDFALL
ELIMINATION PROVISION INPUT
**DISPLAY ONLY**
[1]
TRANSFER TO: XXXX
INPUT
WEPI

WINDFALL ELIMINATION PROVISION

[2]
NH SSSSSSSSS SSSSS SSSSSSSSSS
[3]
AGENCY/ORGANIZATION:
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
[4]
ADDRESS: SSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSSSS
[5]

[6]

SOURCE OF PENSION: S IF STATE SELECTED, SHOW ABBREVIATION:
SS
1. OPM
[7]

2. STATE(INCLUDES GU,PR,SM,VI) 3. US GOVT 4. OTHER
[8]

ELG DATE OF PENSION (MMYY): SSSS ENT DATE OF PENSION
(MMYY): SSSS
[9]
GROSS MONTHLY PENSION AMT AT FIRST MONTH OF CONCURRENT
ENTITLEMENT TO
PENSION SOCIAL SECURITY BENEFIT: SSSSSSS
[10]
OR, LUMP SUM AMOUNT: SSSSSSSSS

IF LUMP SUM, ENTER PERIOD COVERED BY LUMP SUM
[11]

[12]

[13]

BEGINNING (MMYY): SSSS THROUGH (MMYY): SSSS OR TOTAL
MONTHS: SSS
[14]

[15]

PROOF OF PENSION AMT (P/N): S IF PENSION ENDED, DATE LAST
RECD (MMYY): SSSS
[16]
IS PENSION BASED ON MONTHS OF COVERED AND NON-COVERED
SERVICE (Y/N): S
[17]

[18]

[19]

TOTAL PENSION PERIOD (MMYY) FROM: SSSS TO: SSSS OR TOTAL
MONTHS: SSS
[20]

[21]

[22]

NONCVRD PERIOD AFTER 1956 (MMYY) FROM: SSSS TO: SSSS OR
TOTAL MONTHS: SSS
[23]
MORE (Y/N): S

[24]
PENSION S OF S

FACSIMILE: WEPI - Windfall Elimination Provision Input
MCS

WINDFALL ELIMINATION PROVISION INPUT

WEPI

[1-C]
TRANSFER TO: XXXX
NH SSSSSSSSS SSSSS SSSSSSSSS CL SSSSSSSSSS SSSSS
SSSSSSSSS
AGENCY/ORGANIZATION:
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
ADDRESS: SSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSS
[2-C]

[3-C]

SOURCE OF PENSION: P IF STATE SELECTED, SHOW
ABBREVIATION: PP
1. OPM 2. STATE (INCLUDES GU, PR, SM, VI) 3. US GOVT 4. OTHER
[4-M]

[5-C]

ELG DATE OF PENSION (MMYY): PPPP ENT DATE OF PENSION
(MMYY): PPPP
[6-M]
GROSS MONTHLY PENSION AMT AT FIRST MONTH OF CONCURRENT
ENTITLEMENT TO
PENSION & SOCIAL SECURITY BENEFIT: PPPPPPP
[7-C]
OR LUMP SUM AMOUNT: PPPPPPPPP
IF LUMP SUM, ENTER PERIOD COVERED BY LUMP SUM

[8-C]

[9-C]

[10-C]

BEGINNING (MMYY): PPPP THROUGH (MMYY): PPPP OR TOTAL
MONTHS: PPP
[11-M]

[12-C]

PROOF OF PENSION AMT (P/N): P IF PENSION ENDED, DATE LAST
RECD (MMYY): PPPP
[13-M]
IS THE PENSION BASED ON BOTH COVERED AND NON-COVERED
SERVICE MONTHS (Y/N): P
[14-C]

[15-C]

[16-C]

TOTAL PENSION PERIOD (MMYY) FROM: PPPP TO: PPPP OR TOTAL
MONTHS: PPP
[17-M]

[18-M]

NONCVRD PERIOD AFTER 1956 (MMYY) FROM: PPPP NONCVRD
PERIOD AFTER 1956 (MMYY) TO: PPPP
[19-C]
NONCVRD PERIOD AFTER 1956 (MMYY) OR TOTAL MONTHS: PPP
[20-O]
MORE (Y/N): X

[21-D]
PENSION S OF S