SSA-2010 Current Version

OMB 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 (01-2011)

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5. Have you ever been deported or been removed from the United States?
Date of deportation or removal
Yes
No

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
income

Form SSA-2010-F6 (01-2011)

Amount of income
and currency type

Page 2

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.

Form SSA-2010-F6 (01-2011)

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

Form SSA-2010-F6 (01-2011)

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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.

Form SSA-2010-F6 (01-2011)

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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 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 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.

Form SSA-2010-F6 (01-2011)

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