Form SSA-2000 Application for Special Benefits for World War II Vetera

FORM APPROVED
OMB NO. 0960-0615

SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS
FILING DATE
Month, Day, Year

I am applying for all benefits for which I am eligible under title VIII
(Special Benefits for Certain World War II Veterans) of the Social
Security Act, and for benefits under other programs administered by
the Social Security Administration.

Actual
or
Protective
(b) Enter your date of birth
Month, Day, Year

1. (a) Print your name (First Name, Middle Initial, Last Name)

2. (a) Enter your Social Security Number
(b) Did you ever use any other names (including maiden name) or other Social
Security Numbers (SSN)?
(c) Other Names or SSNs Used

3.

Sex

male

YES

NO

YES

NO

YES

NO

YES

NO

female

4. (a) Have you (or has someone on your behalf) ever filed an application for
Supplemental Security Income (SSI)?
(b) Are you currently receiving SSI payments?
If “NO,” when did you last receive SSI payments?

Month
Year
5. (a) Were you in the active military, naval or air service of the United States after
September 15, 1940 and before July 25, 1947?
(b) Enter dates of service.

From: (Month, Year)

To: (Month, Year)

6. (a) Were you in the organized military forces of the Government of the Commonwealth
of the Philippines, while the forces were in the service of the Armed Forces of the
United States pursuant to the military order of the President dated July 26, 1941?
This includes organized guerrilla forces under commanders appointed, designated,
or subsequently recognized by the Commander in Chief, Southwest Pacific Area, or
other competent authority in the Army of the United States. You must have been in
this service after July 25,1941 and before December 31,1946.
(b) Enter dates of service.

From: (Month, Year)

YES

NO

To: (Month, Year)

IF YOU ANSWER “NO” TO ITEMS 5 AND 6, GO ON TO SIGNATURE BLOCK ON PAGE 4.
Form SSA-2000 (XX-XXXX)
Destroy Prior Editions

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7. (a) During the past 12 months, did you receive income from any of the following sources?

INCOME SOURCES

Yes

No

Dates Received
From:
To:

Monthly Amount

FEDERAL BENEFITS
Social Security (This does not include SSI)
Railroad Retirement
Veterans Affairs
Office of Personnel Management (Civil Service)
Military Pension
Black Lung
Bureau of Indian Affairs
STATE/LOCAL BENEFITS
Unemployment Compensation
Workers’ Compensation
State Disability
State or Local Pension
PRIVATE BENEFITS
Employer or Union Pension
Insurance or Annuity Payment
OTHER PENSION, ANNUITY, RETIREMENT OR
DISABILITY BENEFIT (Show Source)

(b) During the past 12 months, did you receive a lump sum payment, instead of monthly
or other recurring payments, from any of the above sources?
If “YES,” explain below.

8. (a) Have you ever been deported or removed from the United States?
If “YES,” answer (b) and (c) below.
(b) Enter Month, Day, Year you were deported or removed from the United States.
(c) Have you ever been lawfully admitted to the United States for permanent residence
after the date in (b) above?
Form SSA-2000 (XX-XXXX)
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Month

YES

NO

YES

NO

Day
YES

Year
NO

9. Is there 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?

YES

NO

10. Are you currently in violation of a condition of probation or parole imposed under Federal or
State law?

YES

NO

YES

NO

YES

NO

11. (a) Have you established residence outside the 50 States, the District of Columbia, or the
Commonwealth of the Northern Mariana Islands?
If “YES,” complete (c) and (d) below.
If “NO,” complete (b) below.
(b) Do you intend to establish residence outside the 50 States, the District of Columbia or the
Commonwealth of the Northern Mariana Islands?
If “YES,” complete (c) and (d) below.
If “NO,” go to signature block on page 4.
(c) Date residence began or will begin

Month, Day, Year

Date residence ended or will end (if applicable)
(d) Enter below your full address outside the United States (include zip/postal code).

Month, Day, Year

REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)

Form SSA-2000 (XX-XXXX)

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IMPORTANT INFORMATION — PLEASE READ CAREFULLY
• You must tell us about any changes shown on the attached Reporting Instructions within 10 days after the end
of the month it happens.
• The Social Security Administration will check your statements and compare its records with records from other
State and Federal agencies, including the Internal Revenue Service, to make sure you are paid the correct
amount.

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 statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
Date (Month, Day, Year)

SIGNATURE OF APPLICANT

Telephone Number

Signature (First Name, Middle Initial, Last Name) (Write in ink)

Applicant’s Mailing Address (Number & Street, Apt. No., P.O. box)
(Enter Residence Address in “Remarks,” on page 3 if different.)

City and State

Country

ZIP/Postal Code

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses who know the applicant must sign below, giving their full addresses. Also, print the applicant’s name in the
Signature block.
1. Signature of Witness

Address (Number and Street, City, State,
Country and ZIP/Postal Code)

Form SSA-2000 (XX-XXXX)

2. Signature of Witness

Address (Number and Street, City, State,
Country and ZIP/Postal Code)

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REPORTING INSTRUCTIONS
FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS
You must report to Social Security 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 benefits.
• You have been deported or removed from the United States.
• There is 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 a pension, annuity or other recurring payment. This includes payments such as workers’ compensation,
veterans benefits or disability benefits. You must also report if the amount of these payments changes.
• Additionally, your family or other knowledgable person must notify SSA if you die.

HOW TO REPORT
You can make your reports by telephone, mail or in person. You can contact any U.S. Embassy, Consulate, or
any U.S. Social Security Office. If you live in the Philippines, you may contact:
Social Security Administration
1201 Roxas Boulevard
Ermite 0930 Manila
Telephone: 632-301-2000 Ext. 9
Email: [email protected]

Form SSA-2000 (XX-XXXX)

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RECEIPT FOR YOUR CLAIM FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS
NAME

SOCIAL SECURITY NUMBER

DATE

Telephone Number to call if you have a question or something Social Security Office you may contact
to report.

Your application for Special Benefits for World War II Veterans will be processed as quickly as possible. If you have
any questions about your claim, we will be glad to help you. You should hear from us within ______ days after you have given us
all the information we requested. Some claims may take longer if additional information is needed.

PRIVACY ACT NOTICE
Application for Special Benefits for World War II Veterans
Section 806 of Section 251 of P.L. 106-169, authorizes us to collect this information. We will use the information you provide to
determine whether you are eligible for Special Veterans Benefits. Furnishing us this information 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 generally use the information you supply for determining eligibility for Special Veterans Benefits. We rarely use the
information you supply for any purpose other than the reason stated above. However, we may use it for the administration and
integrity of Social Security programs. We may also See
disclose
information to another person or to another agency in accordance
revised
with approved routine uses, which include but are not
limited
to the following:
Privacy Act

Statement under

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
supplementary
2. To comply with Federal laws requiring the release
of information from Social Security records (e.g., to the Government
documents
of
Accountability Office and Department of Veterans’
Affairs);
collection
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
insturment.
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 the Census and private concerns under contract to Social Security).
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.
A complete list of routine uses for this information is available in our System of Records Notices entitled, Master Files of Social
Security Number (SSN) Holders and SSN Applications, 60-0058; Claims Folders System, 60-0089; Supplemental Security
Income Record and Special Veterans Benefits, 60-0103; and Social Security Title VIII Special Veterans Benefits Claims
Development and Management Information System, 60-0273. These notices, additional information regarding this form, and
information regarding our systems and programs, are 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. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-2000 (XX-XXXX)

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