SSA-58 Modified Benefit Formula Questionnaire-Employer

Form SSA-58 (03-2020) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 2
OMB No. 0960-0477

MODIFIED BENEFIT FORMULA QUESTIONNAIRE - EMPLOYER
Social Security Administration
To Agency/Employer:

Date:

Claimant:

Social Security Number:

We need this information in connection with a claim for Social Security Benefits. Please respond by
If you have any questions about this request, please contact:
1. Indicate the first month and year for which
could have received a pension from your organization, even though this may not be the actual
retirement date.
Month
Year
If the above date is before January 1986, do not answer the remaining questions.
2. The period(s) of employment on which the pension is based are:
From:
To:

Month

Day

Year

Month

Day

Year

3. The period(s) of employment after 1956 not covered by Social Security used to determine the amount of
the pension are:
From:
Month
Day
Year
To:

Month

Day

Year

4. Indicate the amount of the pension before any deductions are made to provide for a survivor annuity,
health insurance, etc. as of
Amount: $
5. If a lump sum was paid in lieu of a monthly pension, enter the amount of the payment and the specific
period of time for which the payment was made:
Amount: $
for the period.
From:
To:

Month

Year

Month

Year

Name of Person Providing Information

Telephone Number

Form SSA-58 (03-2020) UF

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See Revised
Privacy Act Statement
Privacy Act
Collection and Use of Personal Information
Statement
Sections 205(a), 205(c)(2), 215(a)(7), and 215(d)(3) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of
the information may delay a determination of any Social Security benefits and could result in a referral to the
Internal Revenue Service.
We will use the information to verify the claimant's statements about employment and make a determination
of eligibility for Social Security benefits. We may also share this information for the following purposes,
called routine uses:
1. To employers or former employers, including State Social Security administrators, for correcting and
reconstructing State employee earnings records and for Social Security purposes;
2. To specified business and other community members and Federal, State, and local agencies for
verification of eligibility for benefits under section 1631(e) of the Social Security Act; and
3. To student volunteers, individuals working under a personal services contract, and other workers
who technically do not have the status of Federal employees, when they are performing work for the
Social Security Administration, as authorized by law, and they need access to personally identifiable
information in SSA records in order to perform their assigned Agency functions.
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) 60-0059,
entitled Earnings Recording and Self-Employment Income System; 60-0089, entitled Claims Folders
Systems; and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our
SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement

See Revised PRA
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 (OMB) control number. We estimate that it will take about 20 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.