Form Ssa-2490-Bk - Application For Benefits Form Page 4
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7PART II
Complete Part II ONLY if you are claiming benefits from a foreign country.
If you are applying for sickness or disability/invalidity benefits, enter the
8.
Date
(Month, day , year)
date you became disabled. Otherwise enter ''N/A.''
9.
(a) If you are applying for retirement/old-age benefits, have you stopped
Yes
No
or do you plan to stop working?
(If "No" go on
(If "Yes" answer
to item 10.)
(b) below.)
(b) If ''Yes,'' enter the date you stopped or plan to stop working.
Date
(Month, day , year)
(a) Are you applying for foreign social security benefits under a special
10.
Yes
No
system that covers a specific occupation (e.g., miners, seamen,
(If "No" go on
(If "Yes" answer (b)
farmers)?
to item 11.)
and (c) below.)
(b) What was your occupation in the foreign country?
(c) Did you perform the same type of work in the U.S?
Yes
No
INFORMATION ABOUT THE APPLICANT
Complete item 11 ONLY if you are not the worker. If you are the worker, leave this question blank and go on to
item 12.
(b) What is your relationship to the
(a) Print your name (First name, middle initial, last name, maiden name)
11.
worker?
(c) Enter your U.S. Social Security number
(d) Enter your social insurance number in the
foreign country
(if none or unknown, so
indicate)
ADDITIONAL INFORMATION ABOUT THE WORKER
(a) Enter worker's date of birth (Month, day, year)
(b) Enter worker's place of birth (City, state, province,
12.
country)
If the worker is deceased, enter the
13.
(a) Date (Month, day, year)
(b) Place (City, state, province, country)
date and place of death
(a) Was the worker in the active military or naval service of the
14.
Yes
No
U.S. (including U.S. reserve or U.S. National Guard active
duty for training) or a foreign country after September 7,
(If "No"go on
(If "Yes" answer (b)
1939?
to item 15.)
thru (c) below.)
Dates of Service
(b) Enter the name of country served
Country
and dates of service:
FROM:
TO:
(Month, day , year)
(Month, day , year)
(c) Has anyone (living or deceased) received, or does anyone expect to
Yes
No
receive, a benefit from any U.S. Federal agency based on the worker's
(If "Yes" answer (d)
(If "No" go on
military or naval service?
below
to item 15
(d) If ''Yes'' enter the following information for each person:
(If additional space is required, enter the information in
Remarks -- item 19)
Name
U. S. Agency
Claim No.
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 4
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