Ssa-3885

Form SSA-3885 (02-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 3
OMB No. 0960-0160

Government Pension Questionnaire
Name of Wage Earner or 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(k)(5) 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 prevent an accurate and timely decision on your claim and
could affect your Social Security benefit. We will use the information to determine the effect of your pension on your Social
Security benefit. We may also share the information for the following purposes, called routine uses: 1. To contractors and other
Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration of its programs; and, 2. 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 SSA, 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 Notices (SORNs) 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 - 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

(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 an 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?

Day

Year

Local

(b) On the date shown in (a) above, was this employment covered under Social Security
for benefit purposes?
3.

Month

Yes
Month

Yes
Month
Yes
Month

No
Year

No
Year
No
Year

Form SSA-3885 (02-2018) UF
5.

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(a) Do you receive your pension/annuity weekly, biweekly, or monthly?
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?
If yes, what is the amount of the annuity before reduction for the lump sum?

No

Yes

No

Yes

No

$

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

Yes

$

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
been receiving spouse's or surviving spouse's Social Security benefits?
If yes, give the former amount(s) and date(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 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?

Remarks

Yes

No

(If yes, answer (b).)
Yes

No

Form SSA-3885 (02-2018) UF

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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

Witness are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witness 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)

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