This is a very important letter that could affect whether __(1)__ can get Special Veterans Benefits (SVB). Please read it carefully. If there is anything you do not understand, please get in touch with us right away.

What You Need to Do

We need more information to make a decision on __(2)__ application for SVB. Therefore, it is important that you send us the information shown under “Things We Need,” as soon as possible. Please use the enclosed envelope to return information to us.

If We Do Not Hear From You

We may deny __(3)__ application for SVB if you do not respond to this request or contact us by (4) to tell us why.

 

If we deny __(5)__ application, we will send you another letter to explain our decision. The letter will also explain how to appeal if you disagree with our decision.

Things We Need

We need to see an original or certified copy of the following item(s). We cannot accept photocopies or copies signed by a notary public. You should bring or mail these documents to us. If you mail them, please use the enclosed envelope. We will return these items to you.

Even if you don't have all of the information, we need to hear from you. 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)__ the 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 of benefit income (such as award notices or other statements) showing the amount of, and date of entitlement to, __(1)__.

[Optional Paragraph For Tailoring A Request For Evidence]

If You Have Questions or Need Help

• •

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

• •

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

• •

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

If you call or visit an office, please have this letter and the enclosed envelope with you.

Notice Fill-ins:

1. (1) 

   (you) or (veteran's name)

2. (2) 

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

3. (3) 

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

4. (4) 

   (Month/Day/Year) 30 days after the date of this notice

5. (5) 

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

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 (he, she)

4. (4) 

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

5. (5) 

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

6. (6) 

   (you) or (veteran's name)

7. (7) 

   (you) or (veteran's name)

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) 

   (Type of benefit income receiving)

The FO is responsible for sending this notice. However, in cases where the claim originated in an area not serviced by an FO (or the FSP), the CPS is responsible for sending this notice.

Select the Optional Evidence paragraph(s) for the particular type of evidence required. An optional paragraph is provided for tailoring information. 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.