Question 1. SSN, Residence Address of Beneficiary
Enter the beneficiary’s name, SSN, and residence address.
Question 2. Name of Representative Payee, SSN
Enter the representative payee’s name and SSN.
Question 3. Beneficiary Deceased
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a.
If the beneficiary is deceased:
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2.
complete the “Date of Death” line, and
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3.
go to page 3 and review the Penalty of Perjury Warning and Privacy Act Statement.
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b.
If the beneficiary is not deceased:
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Question 4. Returned to the United States
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a.
If the beneficiary returned to the United States:
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b.
If the beneficiary did not return to the United States:
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Question 4. A. Dates of Return to the United States
Enter “from” and “to” dates in month, day, and year format on the chart to indicate
the length of time the beneficiary returned to the United States. Go to question 5.
Question 5. Deportation from the United States
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a.
If the Department of Homeland Security (DHS) deported the beneficiary during any visits
to the United States:
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2.
complete “Date of deportation or removal” line, and
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b.
If DHS did not deport the beneficiary during any visits to the United States, go to
question 6.
Question 6. Other Benefit Income
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a.
If the beneficiary is receiving other benefit income besides SVB payments, mark the
“Yes” box.
NOTE: Other benefit income includes, but is not limited to, the following:
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•
Railroad retirement benefits
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•
U.S. Veterans Affairs compensation and pension benefits
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•
Foreign Veterans benefits. For example, Philippine Veterans Administration (PVAO),
Philippine Social Security System (SSS), Canada Pension Plan and Old Age Security
(CPP and OAS), Civil Service benefits (e.g., Philippine Government Service Insurance
System (GSIS)
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•
Military pensions (e.g., AFP in the Philippines)
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•
Bureau of Indian Affairs benefits
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•
Unemployment Compensation
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•
State, local, or foreign government pensions or disability benefits
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•
Employer or union pension
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•
Insurance or annuity payments
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•
Individual Retirement Account (IRA) payments
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b.
If the beneficiary is not receiving benefit income other than SVB payments, mark “No”.
Question 7. Other Benefit Income Chart
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a.
Enter the source that is making payment to the beneficiary. List the income sources
in chronological order.
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b.
Enter the current amount of monthly income and type of currency received.
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c.
Enter “from” and “to” date in month, date, and year format (MM/DD/YY).
NOTE: Use the “Remarks” section to indicate the frequency and amount of any recurring payments
that are not paid monthly.
The definition of recurring payment is in Other Benefit Income VB 00205.100B.2.
Instructions for how to determine monthly income recurring amount are in Determining
Monthly Income Amount VB 00205.115.