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CSU Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security
Human Resources

Employee and Campus Information

First name Required

Middle name

Last name Required

Employee ID

Campus Required

Hayward Hills Campus

Concord Campus

Oakland Professional Development and Conference Center

Department Required

Please be advised that your earnings from this position are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this position. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension benefit may affect the amount of the Social Security Benefit you receive. Your Medicare benefits, however, will not be affected.

Under the Social Security law, there are two (2) ways your Social Security benefit amount may be affected:

1. Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job.

For example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit.

2. Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State, or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds (2/3) of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500-$400 = $100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65.

FOR ADDITIONAL INFORMATION

For more information, please refer to Social Security Publications "Windfall Elimination Provision," and "Government Pension Offset Provision." These publications, and additional pertinent information, including information about exceptions to each provision, are available at https://www.ssa.gov/. You may also call toll free at (800) 772-1213, or the TTY number at (800) 325-0778, or contact your local Social Security Office.

Required Signature

I certify that I have received CSU FORM SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security benefits.

E-signature Required (full name e-signature)

Date Required

Campus name Required

Employer ID Required

Technical Letter – HR/Benefits 2005-05 – Attachment B

Privacy Notice

The Information Practice Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be provided when collecting personal information from individuals.

The principal purpose for requesting information on this form is to verify your identity, and to comply with federal law. CSU policy and state and federal statutes authorize the maintenance of this information.

It is mandatory to furnish all information requested on this form.

CSU requires employee’s social security number and name for identification purposes. Legal references authorizing maintenance of this information include Government Code Sections 1151 and 1153, Sections 6011 and 6051 of the Internal Revenue Code, and Regulation 4, Section 404.1256, Code of Federal Regulations, under Section 218, Title II of the Social Security Act.

Information provided on the form will be forwarded to the appropriate governmental agency. The official(s) responsible for the maintenance of the forms is:

UC HR/Benefits
Records Management
P.O. Box 24570
Oakland, CA 94623-1570

CalPERS – Form SSA-1945
P.O. Box 942715
Sacramento, CA 94229-2715