Form Ssa-2000-F6 - Application For Special Benefits For World War Ii Veterans (Page 2 of 6) in pdf

Form Ssa-2000-F6 - Application For Special Benefits For World War Ii Veterans Page 2

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

Dates Received

INCOME SOURCES

Yes

Monthly Amount

From:

To:

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

YES

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?

YES

If “YES,” answer (b) and (c) below.

(b) Enter Month, Day, Year you were deported or removed from the United States.

Month

Day

Year

YES

after the date in (b) above?

Form SSA-2000-F6 (09-2016)

Page 2

Form Ssa-2000-F6 - Application For Special Benefits For World War Ii Veterans Page 2