Form Ssa-2490-Bk - Application For Benefits Form Page 6

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18.
(a) Has the worker, or any other person listed on this application, ever previously
Yes
No
applied for U.S. Social Security benefits or social insurance benefits from the
country shown in item 3 of this application?
(If "Yes" answer (b)
(If "No" go on
thru (f) below.)
to item 19.)
If "Yes" enter the information requested for each person. I(If additional space is required, enter the
information in Remarks -- item 19.)
(b) Name
(c) Type of benefit (e.g., Retirement)
(d) Claim Number
(e) Amount of benefit
(f) Agency which approved or denied claim
(if benefit awarded)
19.
(You may use this space for any explanations. If you need more space, attach a separate sheet.)
REMARKS
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 30 minutes to read the instructions, gather the
facts, and answer the questions.
SEND THE COMPLETED FORM ALONG WITH ANY EVIDENCE TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.
Page 6
Form SSA-2490-BK (4-2004)
EF (4-2004)

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