Social Security Administration
Potential Private Pension Benefit Information
Social Security
Number
Name
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 Plan Number
Identification Number
Year Reported Estimated Amount
Plan Administrator and Address Type of Annuity Payment Frequency
Units or Share Value of Account
IMPORTANT: This is all the information we have. See the other side of this page for an explanation
of this information
For SSA Use Only: Form SSA-L99-C1 (1-91) (Front)
EXPLANATION OF INFORMATION
YEAR
REPORTED
|
This is the year for which the Plan Administrator reported the pension plan information
to the Internal Revenue Service.
|
ESTIMATED
AMOUNT
|
This is the Plan Administrator's estimate of pension benefits that may be paid at
the normal retirement age. The actual method and/or amount of payment may differ because
of benefit options you select or changes in the plan itself.
|
TYPE OF
ANNUITY
|
The code listed identifies the type of annuity to be paid. It is based on the type
of annuity in use under the plan at the time the worker stopped working under the
plan.
|
| |
- A
-
A single payment of a lump sum
- B
-
Annuity payable over a fixed number of years
- C
-
Life annuity
- D
-
Life annuity with period certain
- E
-
Cash refund life annuity
- F
-
Modified cash refund life annuity
- G
-
Joint and last survivor annuity
- M
-
Other (Type of annuity not reported)
|
PAYMENT
FREQUENCY
|
The code listed shows how often payments will be made during a 12 month period. |
| |
- A
-
Lump sum
- B
-
Annually
- C
-
Semi-annually
- D
-
Quarterly
- E
-
Monthly
- M
-
Other (Payment frequency not reported)
|
UNITS OR
SHARES
|
If the pension amount is based on units, the number of units credited will be shown.
If the pension amount is based on shares of stock, the number of shares will be shown
followed by “S” to indicate shares.
|
VALUE OF
ACCOUNT
|
If shown, this indicates the value of the account at the time the worker stopped working
under the plan.
|
|
OTHER IMPORTANT INFORMATION
|
WRONG
ADDRESS OR
COMPLAINTS
|
If the pension plan address on page 1 proves to be wrong, or if you have a complaint
about your claim for private pension benefits, you should contact the local office
of the Department of Labor's Pension and Welfare Benefits Administration that is listed
in your local telephone directory. If there is no listing in the local directory,
you should write to the Department of Labor, Pension and Welfare Benefits Programs,
Room 4659, 3rd Street and Constitution Avenue N.W., Washington, DC 20216.
|
Form SSA-L99-C1
(1-91)(Back)