VB 01701.015 Completion of Form SSA-2010-F6
Form SSA-2010-F6 (Statement for Determining Continuing Entitlement for Special Veterans Benefit (SVB)) establishes continued eligibility to SVB payments.
B. Description of SSA-2010-F6
The SSA-2010-F6 contains a "Questionnaire”, “Receipt for Benefit Review", and “Reporting Instructions”.
C. Completion of the questionnaire
The beneficiary or representative payee completes the questions. The Foreign Service Post (FSP), or the Social Security Administration (SSA), may assist the beneficiary or the representative payee to complete the form.
1. Completing the top-left portion of the form beside the “FOR SSA USE ONLY” block
FSP or SSA enters the beneficiary’s or representative payee’s name and mailing address.
2. Completing the “FOR SSA USE ONLY” block
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.
3. Completing the numbered questions
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
If the beneficiary is deceased:
mark the “Yes” box,
complete the “Date of Death” line, and
go to the last page, sign, and date the form.
If the beneficiary is not deceased:
mark the “No” box, and
go to question 4.
Question 4. Returned to the United States
If the beneficiary returned to the United States:
mark the “Yes” box, and
go to 4A.
If the beneficiary did not return to the United States:
mark the “No” box, and
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
If the Department of Homeland Security (DHS) deported the beneficiary during any visits to the United States:
mark “Yes” on the box,
complete “Date of deportation or removal” line, and
go to question 6.
If DHS did not deport the beneficiary during any visits to the United States, go to question 6.
Question 6. Other Benefit Income
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
State, local, or foreign government pensions or disability benefits
Employer or union pension
Insurance or annuity payments
Individual Retirement Account (IRA) payments
If the beneficiary is not receiving benefit income other than SVB payments, mark “No”.
Question 7. Other Benefit Income Chart
Enter the source that is making payment to the beneficiary. List the income sources in chronological order.
Enter the current amount of monthly income and type of currency received.
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.
4. Completing Remarks
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.
5. Completing the Signature of Beneficiary or Representative Payee box
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).
6. Completing the Witness box
For the procedure on signature made by a mark, see RSDI Applications – Signature GN 00205.115C.1.