FSP or SSA enters the beneficiary’s or representative payee’s name and mailing address.

FSP or SSA enters the date when mailing the form to the beneficiary. Similarly, record the date when receiving the form from the beneficiary, and enter the processing office name and the reviewer name.

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

1. a. 

   If the beneficiary is deceased:

   1. 1. 

      mark the “Yes” box,

   2. 2. 

      complete the “Date of Death” line, and

   3. 3. 

      go to the last page, sign, and date the form.

2. b. 

   If the beneficiary is not deceased:

   1. 1. 

      mark the “No” box, and

   2. 2. 

      go to question 4.

Question 4. Returned to the United States

1. a. 

   If the beneficiary returned to the United States:

   1. 1. 

      mark the “Yes” box, and

   2. 2. 

      go to 4A.

2. b. 

   If the beneficiary did not return to the United States:

   1. 1. 

      mark the “No” box, and

   2. 2. 

      go to question 5.

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

1. a. 

   If the Department of Homeland Security (DHS) deported the beneficiary during any visits to the United States:

   1. 1. 

      mark “Yes” on the box,

   2. 2. 

      complete “Date of deportation or removal” line, and

   3. 3. 

      go to question 6.

2. b. 

   If DHS did not deport the beneficiary during any visits to the United States, go to question 6.

Question 6. Other Benefit Income

1. 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:

   • •

     Title II benefits

   • •

     Railroad retirement benefits

   • •

     U.S. Veterans Affairs compensation and pension benefits

   • •

     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)

   • •

     Military pensions (e.g., AFP in the Philippines)

   • •

     Black Lung benefits

   • •

     Black Lung benefits

   • •

     Bureau of Indian Affairs benefits

   • •

     Unemployment Compensation

   • •

     Workers’ Compensation

   • •

     State, local, or foreign government pensions or disability benefits

   • •

     Employer or union pension

   • •

     Insurance or annuity payments

   • •

     Individual Retirement Account (IRA) payments

2. b. 

   If the beneficiary is not receiving benefit income other than SVB payments, mark “No”.

Question 7. Other Benefit Income Chart

1. a. 

   Enter the source that is making payment to the beneficiary. List the income sources in chronological order.

2. b. 

   Enter the current amount of monthly income and type of currency received.

3. 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.

This section provides space to include additional information needed for questions. Complete this section if the beneficiary is explaining a previous answer or is providing other information. Please write the number of the question first and then the remark.

The beneficiary or representative must sign and date the form. Include the telephone number, mailing address, city, state, country, and postal code.

If the beneficiary cannot furnish a signature, see the procedure on signature made by a mark or signature made by thumbprint in RSDI Applications – Signature GN 00205.115. Alternative signature method is acceptable (for applicability instructions, see GN 00201.015).

For the procedure on signature made by a mark, see RSDI Applications – Signature GN 00205.115C.1.