Form SSA-2010 Questionnaire About Special Veterans Benefits

Social Security Administration

OMB Approved
OMB No. 0960-XXXX

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.

Social Security Number
-

-

Is the Beneficiary deceased?
Yes

Date of Death______________________

If beneficiary is deceased, go to last page, sign, date, and provide your
information as requested.
No

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
Mo-Day-Year

5.

6.

TO
Mo-Day-Year

Have you ever been deported or been removed from the United States?
Yes

Date of deportation or removal __________________

No

Go to question 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
income

Amount of income
and currency type

FROM
Mo-Day-Year

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

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

PRIVACY ACT NOTICE
We are authorized to collect the information on your application form under Section 808 and 810 of the Social
Security Act and P.L. 106-169. We will use the information you provide on your application to determine if you
are entitled to Special Veterans Benefits. Your response to this request is voluntary. However, failure to provide
all or part of the 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 Social Security 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 Social
Security in establishing rights to Special Veterans Benefits; (2) to comply with Federal laws requiring the
release of information from Social Security records (e.g., to the 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 of
Social Security programs.
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. Information from these matching
programs can be used to establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is
available on-line at www.socialsecurity.gov or at any 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.

REPORTING INSTRUCTIONS FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS

You must report to the Social Security Administration if:
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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 other 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 knowledgeable 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.
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If you live in the Philippines, please call the SSA Division of the Veterans Affairs
Regional Office at 632-301-2000, extensions 6302, 6319, or 5085 from 8 a.m. to
3 p.m., Monday through Friday. You may write or visit the SSA Division, U.S.
Department of Veterans Affairs, 1131 Roxas Boulevard, Ermita 0930 Manila.
You also may E-mail the Veterans Affairs Regional Office 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 at 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.