This is to notify you that __(1)__ for Special Veterans Benefits (SVB) under the provisions of Title VIII of the Social Security Act. The rest of this letter will tell you more about our decision.

What You Must Do To Get SVB Benefits

__(2)__ for SVB, but __(3)__ must reside outside the United States to be entitled to receive SVB payments. This means establishing a residence outside the United States where __(4)__ to continue to live. Outside the United States means outside the 50 States, the District of Columbia and the Commonwealth of the Northern Mariana Islands.

__(5)__ four months after the month this notice is sent to begin residing outside the United States. This means __(6)__ must begin residing outside the United States no later than __(7)__ or we will deny your claim.

What Will Happen

SVB payments will begin when we receive evidence that __(8)__ residing outside the United States. Benefits may be paid for each month __(9)__ residing outside the United States on the first day of the month, but no earlier than the month after you filed the SVB application.

What To Do Next

You should contact us as soon as __(10)__ residing outside the United States. We will need the new address. We will also need evidence showing the date __(11)__ started residing outside the United States. You should bring this information to the office that services your area as shown in the last section of this letter “If You Have Questions or Need Help.”

What We Need

The information we will need as evidence you are residing outside the United States is shown below. Even if you can't bring us this information right away, we must still hear from you.

We need __(12)__ signed statement showing that __(13)__ established a residence outside the United States, the date this began, and that _(14)_ to continue to live there; and

We also need an original or certified copy of a document from both group number 1. and group number 2. below. We cannot accept photocopies or copies signed by a notary public.

1. 1. 

   __(15)__ 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 __(16)__ arrived in the foreign country of residence; and

2. 2. 

   Documentation of the date __(17)__ 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/she knows __(18)__ residing outside the United States, where __(19)__ residing, when __(20)__ began residing there, and how he/she knows this information.

If We Do Not Hear From You

If you do not bring us evidence by __(21)__that __(22)__ began residing outside the United States, we will deny your claim of entitlement to SVB payments. If we deny your claim, you will have the right to appeal or you may file a new claim.

If You Disagree With the Decision

If you disagree with our decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision with which you disagree and will look at any new facts you have. We may also review those parts with which you agree and may make them unfavorable or less favorable to you.

• •

  You have 60 days to ask for an appeal.

• •

  You must put the request for an appeal in writing.

• •

  The 60 days start the day after you receive this letter.

• •

  You must have a good reason if you wait more than 60 days to ask for an appeal.

• •

  You may make your request through any U.S. Social Security office, United States Embassy or consulate, or the U.S. Veterans Affairs Regional Office in Manila. Or, you may write to us at the address shown at the top of this letter.

Please read the enclosed leaflet, “Your Right to Question the Decision Made on Your Social Security Claim.” It contains more information about the appeal.

If You Have Questions or Need Help

If you have questions, you should contact one of the offices shown below if you are outside the United States. You may also contact us at the address shown at the top of this letter or at any U.S. Social Security office.

If you call or visit an office, please have this letter with you.

• •

  If you live in Canada, contact any U.S. Social Security office.

• •

  If you live in Guam, Puerto Rico, Samoa or the U.S. Virgin Islands, you should contact the nearest U.S. Social Security office.

• •

  If you live in Mexico, contact any U.S. Social Security office or the nearest United States Embassy or consulate.

• •

  In the Philippines, please call 523-1001 extensions 2516 or 2645 from 8:00am to 2:00p.m. or write/visit SSA Division, U.S. Department of Veterans Affairs, 1131 Roxas Boulevard, 0930 Manila.

• •

  If you live in any other country, you should contact the nearest United States Embassy or consulate.

Notice Fill-ins:

1. (1) 

   (you qualify) or (veteran's name qualifies)

2. (2) 

   (You qualify) or (veteran's name qualifies)

3. (3) 

   (you) or (he, she)

4. (4) 

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

5. (5) 

   (You have) or (veteran's name has)

6. (6) 

   (you) or (veteran's name)

7. (7) 

   (last day of the 4th full month after the date of the notice)

8. (8) 

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

9. (9) 

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

10. (10) 

    (you begin) or (veteran's name begins)

11. (11) 

    (you) or (veteran's name)

12. (12) 

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

13. (13) 

    (you) or (veteran's name)

14. (14) 

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

15. (15) 

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

16. (16) 

    (you) or (veteran's name)

17. (17) 

    (you) or (veteran's name)

18. (18) 

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

19. (19) 

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

20. (20) 

    (you) or (veteran's name)

21. (21) 

    (add two weeks to date shown in 7th fill-in)

22. (22) 

    (you) or (veteran's name)

The FO is responsible for sending this notice.

Enclose SSA Pub. 05-10058, “Your Right to Question the Decision Made on Your Social Security Claim.”