Form SSA-2010-F6 Questionnaire About Special Veterans Benefits

Form Approved
OMB No. 0960-0782

Social Security Administration

Statement for Determining Continuing Entitlement for
Special Veterans Benefits (SVB)
FOR SSA USE ONLY
Date Sent
Date Received
Processing Office/Reviewer
Please answer the questions on this form as completely as possible. If you are filling out this form for
someone else, answer the questions as they apply to that person.
1. Name of Beneficiary

Social Security Number

Residence Address of the Beneficiary

2. Name of Representative Payee (if applicable)
3. Is the Beneficiary deceased?
Date of Death
Yes
No

Social Security Number

If beneficiary is deceased, go to last page, sign, date,
and provide your information as requested.

Go to question 4.

4. Since you first began receiving Special Veteran's Benefits, have you returned to the United States
for longer than a full calendar month? If you had a benefit review in the past, provide the
information since the last review.
Yes

Go to 4A.

No

Go to question 5.

A. Provide the dates which you were in the United States for longer than a full calendar month. Be as
detailed as possible, providing at a minimum the month and year that you were in the United States.
FROM
TO
Mo-Day-Year
Mo-Day-Year

Form SSA-2010-F6 (11-2013)
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5. Have you ever been deported or been removed from the United States?
Yes
No

Date of deportation or removal
Go to question 6.

6. Are you receiving income other than SVB?
Yes

Go to question 7.

No

Go to signature page

7. Provide the source and amounts of your benefit income since you began receiving SVB. If you had a
benefit review in the past, provide the information since the last review.
List the source and amount separately in chronological order. If you receive additional income in foreign
currency, please list the type and amount of foreign currency. Please attach evidence of all reported income.
use the remarks section if you need additional space. Do not list any Social Security payments. List any
earned income, pensions or other income you may be receiving.

Source of benefit Amount of income
income
and currency type

Form SSA-2010-F6 (11-2013)

FROM
Mo-Day-Year

Page 2

TO
Mo-Day-Year

REMARKS SPACE: You may use this space for any explanations. If you need more space, attach a
separate sheet of paper. If you are continuing an answer to a question, please write the number of the
question first.

Form SSA-2010-F6 (11-2013)

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IMPORTANT: I declare under penalty of perjury that I have examined all the information on this
form, and on any accompanying statements or forms, and it is true and correct to the best of my
knowledge. I understand that anyone who knowingly gives a false or misleading statement about a
material fact in this information, or causes someone else to do so, commits a crime, may be sent to
prison, face other penalties, or both.
SIGNATURE OF BENEFICIARY OR REPRESENTATIVE PAYEE
SIGNATURE (First name, middle initial, last name)

DATE (Month, Day, Year)
TELEPHONE NUMBER
(include area code)

MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, or Rural Route)

CITY, STATE AND COUNTRY

POSTAL CODE

Witnesses are required ONLY if this statement has been signed by mark (X). If signed by mark (X), two
witnesses to the signing who know the individual must sign below, giving their full addresses.

SIGN HERE

SIGN HERE

ADDRESS (Number and street, City, State and
Postal Code, Country)

ADDRESS (Number and street, City, State and Postal
Code, Country)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 808 and 810 of the Social Security Act, as amended, and P.L. 106-109, authorize us to collect this
information. We will use the information you provide to determine if you are entitled to Special Veteran's
Benefits.
See Revised Privacy Act Statement Attached
Furnishing us this information is voluntary. However, failing to provide all or part of this information could
prevent us from making an accurate and timely decision on your claim, and could result in the loss of some
payments.
We rarely use the information you supply for any purpose other than for determining your entitlement to
Special Veterans Benefits. However, we may use it for the administration and integrity of our programs. We
may also disclose information to another person or to another agency in accordance with approved routine
uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits
and/or coverage.
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity
and improvement of Social Security programs. (e.g., to the Bureau of Census and to private
entities under contract with us).
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. We use the information
from these programs to establish or verify a person's eligibility for federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of Records
Notices entitled, Supplemental Security Income Record and Special Veterans Benefits, 06-0103, and Social
Security Title VIII Special Veterans Benefits Claims Development and Management Information System,
60-0273. Additional information regarding these and other systems of records notices, are available on-line
at www.socialsecurity.gov or at your local Social Security office.
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 20 minutes to read the
instructions, gather the facts, and answer the questions. You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Only comments relating to our time
estimate should be provided, not the completed form.
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REPORTING INSTRUCTIONS FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS
You must report to the Social Security Administration if:
You change your mailing address or residence.
You return to or visit the United States for a calendar month or longer.
You become unable to manage your benefits.
You have been deported or removed from the United States.
You have an unsatisfied warrant for your arrest for a felony crime in the United States, or in U.S.
jurisdictions that do not define crimes as felonies, for a crime that is punishable by death or imprisonment
for a term exceeding one year.
You are in violation of a condition of probation or parole.
You receive an increase or decrease in a pension, annuity or another recurring payment. Some
examples of payments are retirement, workers' compensation, veterans' benefits, or disability benefits.
You move to another country.
Your family, representative payee or other knowledgable person must notify the Social Security
Administration if you die.
HOW TO REPORT

If you are outside the United States and have questions or have changes to report, you may contact one of
the offices shown below.
• If you live in the Philippines, please call the Social Security Administration at: 632-301-2000 Ext. 9 from 8
a.m. to 3 p.m., Monday through Friday. You may write or visit the Social Security Administration,
1201 Roxas Blvd., Ermita 0930 Manila. You also may e-mail the Social Security Administration in Manila,
Philippines at: [email protected]
• If you live in American Samoa, Canada, Guam, Puerto Rico, Samoa or the Virgin Islands, contact the
nearest U.S. Social Security office.
• If you live in Mexico, contact the nearest U.S. Social Security office or the nearest U.S. Embassy or
consulate.
If you live in any other country, contact the nearest U.S. Embassy or consulate. Visit
www.socialsecurity.gov/foreign for a complete list of these offices.
If you are in the United States and have questions, you may visit our website at www.socialsecurity.gov or
call us toll-free at 1-800-772-1213. We can answer specific questions from 7 a.m. to 7 p.m., Monday
through Friday. We can provide information by automated phone service 24 hours a day.

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