Form Ssa-2490-Bk - Application For Benefits Form
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7Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0448
APPLICATION FOR BENEFITS UNDER A U.S.
(Do not write in this space)
INTERNATIONAL SOCIAL SECURITY AGREEMENT
If the worker is living, this application should be completed by or on behalf of the worker. If
the worker is deceased, this application should be completed by one of the worker's survivors
who is claiming benefits under the provisions of the international social security agreement.
PART I
Complete Part I in all cases.
1.
(b) U.S. Social Security Number
(a) Print name of worker (First name, middle initial, last name)
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2.
Provide the following information about the worker's social security credits (coverage) and last place of
residence in the foreign country.
(a) Use columns (1) - (5) to enter information about the worker's periods of employment or self-employment
in the foreign country. (If additional space is required, enter the information in Remarks -- item 19.)
(1) Dates
(2) Name and Address of employer or
(3) Type of Industry
(4) Social Insurance
(5) Name of Agency to which
Worked
self-employment activity
or business
Number used
contributions paid
(From - To)
while working
(b) Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social
insurance system which are not based on employment or self-employment (e.g., coverage for voluntary
contributions, deemed or equivalent coverage, periods of military service, illness, etc.)
(1) Dates
(3) Social Insurance Number used
(4) Name of Agency to which
(2) Type of coverage
Covered
for this coverage if different
contributions paid (if any)
(From - To)
than shown in item 2(a)(4)
(c) Enter the worker's last place of residence in the foreign country:
(City and State or Province)
PLEASE REMOVE PAGE 1 OF THIS FORM BEFORE COMPLETING THE REST OF THE APPLICATION. AFTER APPLICATION IS
COMPLETED AND SIGNED, STAPLE DETACHED PAGE TO APPLICATION.
Form SSA-2490-BK (4-2004) EF (4-2004) (Formerly SSA-2490-F4)
Destroy Prior Editions
Page 1
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