Form Ssa-2490-Bk - Application For Benefits Form Page 3
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1
2
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5
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7I apply for all benefits for which I am eligible under the provisions of the
Name of country
3.
social security agreement between the United States and
This application may be used to claim benefits from the U.S. and/or the foreign country shown in item 3. Check
4.
(X) the block(s) indicating the type of benefit(s) for which you are applying under the country(ies) from which
you are claiming the benefit(s).
BENEFIT CLAIMED FROM FOREIGN COUNTRY
Type of Benefit Claimed From Foreign Country:
Retirement/Old-Age
Survivors
None
Other
Disability or Sickness/Invalidity
(Specify)
BENEFIT CLAIMED FROM THE UNITED STATES
(a) Are you presently receiving benefits from the United States?
Yes
No
(If "No" answer
(If "Yes" answer
(c) below.)
(b) below.)
(b) If you are already receiving U.S. benefits, do you wish to file for a
Yes
No
different type of U.S. benefit?
(If "No" go on
(If "Yes" answer
to item 5.)
(d) below.)
(c) If you are not presently receiving U.S. benefits, do you wish to file
Yes
No
for U.S. benefits at this time?
(If "No" go on
(If "Yes" answer
(d) below.)
to item 5.)
(d) Indicate the type of benefit you wish to claim from the United States:
Retirement
Disability
Survivors
INFORMATION ABOUT THE WORKER
(a) Print worker's name at birth, if different from item 1(a)
5.
(b) Check (X) one for the worker
(c) Enter worker's social insurance number in the foreign country if
different than shown in items 2(a)(4) or 2(b)(3)
Male
Female
(d) If the worker's Social Security number in either the United States or the foreign country is not known,
enter the worker's parents' names:
Mother's name (First name, middle initial, last name, maiden name)
Father's name (First name, middle initial, last name)
(e) Enter the worker's citizenship (Enter name of country)
Do you want this application to protect an eligible spouse's and/or
6.
Yes
No
child's right to Social Security benefits?
(a) Was the worker or any other person claiming benefits on this
7.
Yes
No
application a refugee or stateless person at any time?
(If "Yes" answer
(If "No" go on
(b) below.)
to item 8.)
(b) If "Yes" enter the following information about the person:
Name
Dates of refugee or stateless status
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 3
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