Wage Reports and Pension Information

Social Security Administration

Potential Private Pension Benefit Information
Jane Doe
1234 Holiday Drive
Henderson NV 89012-2518

Refer to: S2ABC3
Date December 6, 2017

Dear: Ms Doe,
We sent the Potential Private Pension Benefit Information notice
to tell you that the URS Corporation had reported that you may be
entitled to benefits from these plans.
We have no say in the administration or benefit policies of any
private pension plans and do not make any decisions about
benefits paid under a private pension plan. Therefore, we are
unable to answer questions about beneficiary entitlement under a
specific private pension plan.
The information we sent you earlier is the only pension
I nformation in our files.
If you have written to the Plan Administrator and had your letter
returned, you may wish to write to the Pension Benefit Guaranty
Corporation, Inquiries Department, 1200 K Street NW, Washington
DC 20005. This corporation is responsible for protecting
individuals' rights under private pension benefit plans.

Social Securtiy Administration

Enclosure

Social Security Administration
Potential Private Pension Benefit Information
Social Security Number

Jane Doe
1234 Holiday Drive
HENDERSON NV 89012-2518

1234-56-7890

Name

Jane Doe

We are writing to tell you that you, or the worker whose Social Security number appears at the top
of this form, MAY be entitled to some private pension benefits upon retirement. Also, your family,
or the worker's family, may be entitled to retirement or survivor benefits.
These Are Not Social Security Benefits
These potential benefits are NOT Social Security benefits and we do not make any decisions
about the payment of these benefits. The following provides some basic information about
these private pension benefits.
Information About Pension Benefits
You have , or the worker has, earned pension rights although no longer employed in a job
covered by the pension plan. These are called "deferred vested benefits." Private pension plan
administrators must provide information about such benefits to us through the Internal Revenue
Service. We provide this information about the pension plan when the individual asks for it
or when a claim is filed for Social Security benefits.
If You Want to Apply for These Benefits
If you want to apply for these pension benefits or have any questions, you should contact the
pension Plan Administrator shown below. Include the 9 digit identification number shown below
and a copy of this notice when you write to the Plan Administrator.
Plan Name

HAPPY HOLIDAY CORPORATION401K
RETIREMENT PLAN FOR SPECIFIED
CONTACT EMPLOYEES

Plan Number

12-45678910-002

Identification Number

12-1222222

Year Reported

Estimated Amount

Type of Annuity

Payment Frequency

2018

Plan Administrator and Address

HAPPY HOLIDAY CORP.
300 S GRAND AVE
LOS ANGELES CA 90071

C
Units or Shares

A
Value of Account

$1.00
IMPORTANT: This is all the infom1ation we have. See other side of this page for an
explanation of this information
For SSA Use Only:

00-000-00-000

2017340
Form SSA-L99 (9-97)