TN 2 (06-96)

NL 00901.010 ERISA Notice


In 1979, the Social Security Administration (SSA) began providing notices of potential private pension eligibility to title II applicants as required by the ERISA Act of 1974.

The Wilkes Barre DOC keys information from the Schedule A of Form 5500, Annual Return/Report of Employee Benefit Plan, sent to SSA by the Internal Revenue Service to create the Private Pension Employer Master File (PPEMF). Once a month, SSA matches the file of applicants for Social Security benefits against the PPEMF. When a match occurs, SSA sends the Form SSA-L99-C1 to persons potentially eligible for private pensions. Also, upon request, SSA will provide an SSA-L99-C1 to those potentially eligible for private pensions.


Social Security Administration

Potential Private Pension Benefit Information


                                                                     Social Security Number




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)


This is the year for which the Plan Administrator reported the pension plan information to the Internal Revenue Service.
This is the Plan Administrator's estimate of