Form Rb1 - Claim For Retirement Benefit - Social Security Board - 2013 Page 2
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2Part II. INSURED PERSON’S DECLARATION Continued. . .
(e) I declare that the information given is true to the best of my knowledge.
______________________
____________________________________
____________________
DAY
MONTH YEAR
SIGNATURE
CLAIMANT’S FULL NAME IN PRINT
NOTE: If you are unable to sign this claim, it may be signed on your behalf by someone who should state that he or
she has done so.
DOCUMENTS TO BE PROVIDED
(i) Employment History
(This form is available at any Social Security Branch Office
)
(ii) Valid Social Security Card
(iii) Birth Certificate OR Valid Passport
(iv) Copy of Account Number
FOR OFFICIAL USE ONLY
Decision on Retirement Benefit Claim
State Benefit Type:
Retirement Pension
Pension Start Date:
________ /_______ / _______
DAY
MONTH
YEAR
Weekly Pension Rate: $___________________
Cheque Number:_________________________
OR
Retirement Grant
Amount of Grant: $_____________________
Cheque Number:_________________________
If disallowed, state the reasons for disallowance: ___________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Amount of Deductions: $______________________
Please indicate reasons for deductions, if any: ____________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Claim Processing
Processing Clerk: _________________________________
___________________
______/______/______
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
Verifier (FCC): ___________________________________
___________________
______/______/______
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
Authorizer (AA/ADMIN): __________________________
___________________
______/______/______
NAME IN PRINT
SIGNATURE
DAY
MONTH
YEAR
Relevant Notes:
__________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Form RB1 (July 2013)
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