SSA-16 MCS Signature Proxy

FACSIMILE: APPL - RSDHI CLAIMS APPLICATION
MCS TRANSFER TO: XXXX RSDHI CLAIMS APPLICATION
APPL
[1-M]
NH NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX XXXX
[2-M]
[3-M]
SSN: SSSSSSSSS SEX: X
NH BIRTHDATE: 99999999
[4-M]
[5-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[6-M]
SELECT CLAIM TYPE(S): 9 9 9 1. RETIREMENT 4. AUXILIARY
7. AGE 72
2. DISABILITY 5. UNINS MED ONLY 8. ESRD
[7-C]
3. SURVIVOR 6. LUMP SUM
ABBREVIATED APPLICATION: X
CLAIMANT (IF DIFFERENT)
[8-C]
NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
[9-C]
[10-C]
[11-C]
SSN: 999999999 SEX: X
BIRTHDATE: 99999999
[12-C]
[13-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[14-C]
[15-C]
RELATIONSHIP TO NH: 9 1. SPOUSE
(SUBSEQUENT CLAIM: 9 ) 1. RIB
2. SPOUSE WITH CHILD IN CARE
2. DIB
3. CHILD
APPLICANT (IF DIFFERENT) 4. DEPENDENT PARENT
[16-C]
NAME:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
[18-C]
[19-C]
SSN: 999999999 EIN: 999999999 WILL APPLICANT BE ENTERED IN RPS (Y/N):
X

FACSIMILE: ADDB - ADDITIONAL BENEFITS
mcs
TRANSFER TO: XXXX
ADDITIONAL BENEFITS
ADDB
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939
(Y/N): X
[2-M]
[3-C]
WORKED IN RR FOR 5 YEARS OR MORE (Y/N): X
SPOUSE (Y/N):X
[4-M]
[5-C]
RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X
SPOUSE (Y/N): X
[6-M]
[7-C]
COVERED UNDER FOREIGN SSA (Y/N): X
COUNTRY: XXXXXXXXXX IF
COVERED
[8-C]
[9-C]
FILING FOR FOREIGN SSA (Y/N): X
REQUIRES FOREIGN QC'S FOR US
FILING (Y/N): X
[10-C]
[11-C]
SPOUSE COVERED UNDER SSA OF OTHER COUNTRY (Y/N): X
COUNTRY:
XXXXXXXXXX
[12-M]
[13-C]
CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X
SPOUSE (Y/N):
X
[14-M]
[15-C]
JAPANESE INTERNEE (Y/N): X
VOW OF POVERTY (Y/N):
[16-M]
QUALIFY FOR US FED/STATE/LOCAL GOVT PENSION BASED ON ANY WORK
YOU PERFORMED
which was NOT COVERED UNDER SSA (Y/N): x
[17-M]
CURRENTLY ENTITLED TO A PENSION NOT COVERED UNDER SSA (Y/N): X
[18-C]
IF NO, DO YOU EXPECT TO BE ENTITLED TO A PENSION NOT COVERED UNDER
SSA IN THE FUTURE
(Y/N): X
[19-C]
IF YES, SHOW FUTURE ENTITLEMENT DATE (MMYY): 9999
[20-M]
CLAIMANT HAS CHILD OF NH IN CARE(Y/N): X
[21-C]

fILING FOR MEDICARE ONLY, RESTRICTING MONTHLY BENEFITS (Y/N): X
[22-C]
WILL MEDICARE APPLY: 9 1. YES 2. NO 3. ALREADY ENROLLED ON ANOTHER
SSN
[23-M]
IF CLAIMANT IS FILING AS A SURVIVING SPOUSE, IS CLAIMANT
FILING FOR BENEFITS ON OWN RECORD (Y/N): X

FACSIMILE: ADDR - APPLICANT MAILING ADDRESS
MCS TRANSFER TO: XXXX APPLICANT MAILING ADDRESS
ADDR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
APPLICANT NAME:
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
[1-M]
ADDRESS: PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
[2-M]
[3-C]
[4-C]
CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
[5-C]
[6-C]
STATE & COUNTY CODE: PPPPPP COUNTY: XXXXXXXXXXXXXXX
[7-C]
[8-C]
COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
CONSUL CODE: PPP
[9-C]
foreign POSTAL ZONE: PPPPPPPPPPPPPPP
[10-C]
address explanation:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
[11-C]
[12-C]
Domestic Phone: XXXXXXXXXX
foreigh phone: xxxxxxxxxxxxxxx
[13-C]
enter phone code: x 1= home 2=work 3=none 4=unk 5=other 6=attorney 7=mobile
transfer to: PPPP

FACSIMILE: CLMR - CL MILITARY RETIREMENT/FEDERAL BENEFIT
MCS 2.5 TRANSFER TO: XXXX CL MILITARY RETIREMENT/FEDERAL
BENEFIT
CLMR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
IF RETIRED FROM MILITARY, BASIS OF RETIREMENT: 9
1. LENGTH OF SERVICE
3. RESERVE SERVICE PAYABLE AT AGE 60
2. DISABILITY
4. OTHER
[2-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[3-C]
IF RETIRED AND SERVICE AFTER DEC 31, 1956, INDICATE BRANCH OF
SERVICE PAYING
BENEFIT: 9
1. ARMY
5. COAST GUARD
2. NAVY
6. PUBLIC HEALTH SERVICE
3. AIR FORCE
7. COASTAL/GEODETIC SURVEY
4. MARINE CORPS
8. OTHER
[4-C]
IF OPTION 8 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[5-C]
WAIVED ALL/PART OF RETIREMENT TO GET VA OR OTHER FED CREDIT (Y/N):
X
[6-C]
IF ELIGIBLE FOR CIVILIAN FEDERAL AGENCY BENEFITS, INDICATE BENEFIT
TYPE: 9
1. SERVICE 2. SURVIVOR 3. DISABILITY 4. OTHER
[7-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[8-C]
NAME OF FED AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[9-C]
[10-C]
[11-C]
YEARS EMPLOYED: 99 DATE CLAIM FILED: 999999 CLAIM NO.:
XXX999999999
[12-C]
MOST RECENT AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[13-C]
[14-C]
[15-C]
CITY: XXXXXXXXXXXXX STATE: XX LAST WORKED: 999999

FACSIMILE: CLMS - CL MILITARY SERVICE PAGE 1
MCS
CL MILITARY SERVICE
CLMS
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
[2-C] [3-C]
FIRST NAME USED IN SERVICE: XXXXXXXXXX MI: X LAST NAME:
XXXXXXXXXXXXXXXXXXX
[4-C]
SERVICE NO: XXXXXXXXX
[5-M]
*RECEIVE OR ELIGIBLE FOR MIL OR CIV FEDERAL AGENCY BENEFIT (SELECT
ONE): x
1=CIVILIAN 2=MILITARY 3=BOTH 4=NONE.
[6-C] [7-C]
[8-C] [9-C] [10-C] [11-C]
[12-C]
[ A/R BRANCH OF SERVICE START END N/E RANK
PROOF
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
[13-C] [14-C]
[15-C] [16-C]
[JAPANESE INTERNEE START END
PROOF HOURLY WAGE
|
999999 999999
X
99999999
|
999999 999999
X
99999999
[17-C]
PF1 FOR HELP MORE (Y/N): X
PAGE: 1
TRANSFER TO: XXXX

FACSIMILE: CLRR - CL RAILROAD EMPLOYMENT
MCS 2.5 TRANSFER TO: XXXX CL RAILROAD EMPLOYMENT
CLRR
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSN: SSSSSSSSS
[1-C]
[2-C]
[3-M]
MONTHS WORKED IN RR AFTER 1936: 999 BEFORE 1937: 999 LAST 18 MOS
(Y/N): X
[4-M]
[5-C]
EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX
[6-C]
IF EMPLOYEE LIVING, REC'D RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS
(Y/N): X
[7-C]
IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS
(Y/N): X
[8-C]
EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X
IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS
BENEFITS:
[9-C]
RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[10-C]
WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[11-C]
DEPT+OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF CLAIMANT EVER RECEIVED RRB BENEFITS:
[12-C]
RR APPLICANT: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO:
XXXXXXXXXXX
[13-C]
[14-C]
RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN:
999999999
[15-C]
RELATIONSHIP: XXXXXXXXXX
[16-C]
BENEFIT TYPE: 9 SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL
[17-C]
HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY
ENTITLEMENT TO
SOCIAL SECURITY BENEFITS (Y/N): X

FACSIMILE: DEPC - DEPENDENT CHILDREN OF NH
MCS 2.5 TRANSFER TO: XXXX DEPENDENT CHILDREN OF NH
DEPC
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
LIST ALL CHILDREN OF NH: UNDER 18
18-19 AND ATTENDING SECONDARY SCHOOL
[1-M]
DISABLED/HANDICAPPED PRIOR TO 22
NAME:
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

FACSIMILE: DISB - DISABILITY INFORMATION
TRANSFER TO: XXXX
DISABILITY INFORMATION
DISB
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
DISABLING
CONDITION:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXX
[2-M]
[3-C]
STILL DISABLED (Y/N): X IF NO, DATE DISABILITY ENDED (MMYY): 9999
[4-M]
[5-M]
BLIND (Y/N): X
FREEZE (Y/N): X
[6-M]
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (Y/N): X
[7-M]
FILED OR INTEND TO FILE FOR: 9 9 9 1. VA 2. WC/Public disability Benefits
3. NOT FILING
[8-M]
[9-C]
DISABILITY WORK RELATED (Y/N):X REASON NOT FILING:
XXXXXXXXXXXXXXXXXXXXXXXXXX
[10-M]
[11-C]
MONEY FROM EMPLOYER AFTER ONSET DATE (Y/N): X
AMOUNT: 99999999
[12-C]
TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[13-M]
[14-C]
ADDITIONAL MONEY EXPECTED FROM EMPLOYER (Y/N): X AMOUNT:
99999999
[15-C]
TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[16-M]
[17-C]
NUMBER OF CHILD CARE YRS: 9 ACTUAL CHILD CARE YRS: 99 99 99 99 99 99
IF PARENT RECEIVED 1/2 SUPPORT AT TIME OF ONSET OF DISABILITY
COMPLETE
[18-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[19-C]
ADDRESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX
[20-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

[21-C]
ADDRESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX
FILED OR INTEND TO FILE FOR OTHER DISABILITY (Y/N): S
SPECIFY:SSSSSSSSSSSSSS

FACSIMILE: EARN - EARNINGS
MCS
EARNINGS
EARN
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
LIST ALL EARNINGS AND TYPES FOR SSSS SSSS SSSS
EARNINGS TYPES ARE:1=FICA WAGES 2=SEI 3=EMPLOYEE REPORTED TIPS
4=RR LAG.
PROOF CODES ARE: P=PROVEN R=READILY AVAILABLE N=NOT AVAILABLE
D=DELETED LAG.
[1-C] [2-C] [3-C] [4-C]
[EARNINGS
YEAR TYPE AMOUNT PROOF
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
[5-C]
COMPUTE BENEFITS AND COMPLETE CLAIM WITHOUT LAG EARNINGS (Y/N): X
TRANSFER TO :XXXX