We are writing to tell you that we must receive a signed application before we can make a decision about your request for Special Veterans Benefits (SVB).

What To Do Next

You should get in touch with us right away to complete an application so we can decide whether __(1)__ qualified for SVB. The sooner we get your signed application, the sooner we can make a decision about whether __(2)__ qualified.

You must file your application by (3) for us to use __(4)_, the date of your request, as the filing date. Otherwise, we will use the date we receive the application as your filing date.

[Optional Paragraph For Offices To Use When Application Is Sent Out For Signature (Application Completed Via Telephone Contact)]

[Optional Evidence Paragraph]

What We Need

If you file an application, we will need an original or certified copy of the following item(s). We cannot accept photocopies or copies signed by a notary public. We will return these items to you.

Even if you don't have all of the information we need, you should complete an application. We will help you get anything you do not have.

[OPTIONAL PARAGRAPHS FOR SPECIFIC REQUIRED EVIDENCE]

[Evidence of age]

We need a public or religious record of birth which was made before age 5. Please see the enclosed list entitled “Instructions for Getting Proof of Age.”

[Evidence of military service]

We need evidence of the period of service in the U.S. military between September 16, 1940 and July 24, 1947. Or, evidence of service in the organized military forces of the Philippines between July 26, 1941 and December 30, 1946.

[Evidence of foreign residence]

We need evidence that _(1)_ residing outside the United States. This includes __(2)__ signed statement showing that __(3)__ established a residence outside the United States, the date this began, and that __(4)__ to continue to live there; and

We also need a document from both group number 1. and group number 2. below:.

1. 1. 

   __(5)__ passport which includes the page(s) showing entry date to the foreign country and exit date from the United States; or

   An airline ticket showing the date __(6)__ arrived in the foreign country of residence; and

2. 2. 

   Documentation of the date __(7)__ began the new living arrangement, such as a lease agreement, rental/mortgage receipts, or a deed of purchase; or

   A signed statement from a local government official or other person saying that he or she knows __(8)__ residing outside the United States, where __(9)__ residing, when __(10)__ began residing there, and how he or she knows this information.

[Evidence of benefit income]

We need evidence (such as award notices or other statements) showing the amount of, and date of entitlement to, any benefit income _(1)_ receiving. Benefit income means an annuity, pension, retirement, or disability benefit. It includes any veterans' compensation or pension, workmen's compensation payment, old-age, survivors, or disability insurance benefit, railroad retirement annuity or pension, unemployment insurance benefit, or any other type of benefit income. It does not include a Supplemental Security Income payment. Please note that we do not need evidence of a U.S. Social Security benefit.

What Will Happen

If you complete an application, we will review the case and make a decision about whether __(5)__ qualified. If you disagree with what we decide, you will be able to appeal the decision. We will explain how you can appeal in our decision notice.

If You Have Questions or Need Help

If you have questions or need help, you may call, write, or visit our office or any U.S. Social Security office. Please have this letter with you. If you call or visit our office, please ask for __(6)__. The telephone number is shown at the top of page one.

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Notice Fill-ins:

1. (1) 

   (you are) or (veteran's name is)

2. (2) 

   (you are) or (veteran's name is)

3. (3) 

   (Month/Day/Year) 60 days after the date of this notice

4. (4) 

   (Month/Day/Year) date of protective inquiry

5. (5) 

   (you are) or (veteran's name is)

6. (6) 

   (Name of office contact)

Evidence of foreign residence Fill-ins:

1. (1) 

   (you are) or (veteran's name is)

2. (2) 

   (your) or (possessive form of veteran's name)

3. (3) 

   (you) or (veteran's name)

4. (4) 

   (you intend) or (he intends, she intends)

5. (5) 

   (your) or (possessive form of veteran's name)

6. (6) 

   (you) or (he, she)

7. (7) 

   (you) or (he, she)

8. (8) 

   (you are) or (veteran's name is)

9. (9) 

   (you are) or (veteran's name is)

10. (10) 

    (you) or (veteran's name)

Evidence of benefit income Fill-in:

1. (1) 

   (you are) or (veteran's name is)

The servicing FO is responsible for sending this notice. If the applicant is in the Philippines, the FSP is responsible for sending this notice.

Select the Optional Paragraph Space when an application is being sent in the mail and provide instructions for the applicant.

If evidence is being requested, select the appropriate paragraph(s) for the particular type of evidence required. If proof of age is being requested, enclose the form SSA-L401A FC, “Instructions for Getting Proof of Age.”

NOTE: Form SSA-L401A FC is currently being revised and supplies are limited. If there is difficulty obtaining this form, please call the Office of International Programs at (410) 965-3568.