Form SSA-2490-BK Application for Benefits Under a U.S. International Social Security Agreement

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Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0448
APPLICATION FOR BENEFITS UNDER A U.S.
(Do not write in this space)
INTERNATIONAL SOCIAL SECURITY AGREEMENT
If the worker is living, this application should be completed by or on behalf of the worker. If
the worker is deceased, this application should be completed by one of the worker's survivors
who is claiming benefits under the provisions of the international social security agreement.
PART I
Complete Part I in all cases.
1.
(b) U.S. Social Security Number
(a) Print name of worker (First name, middle initial, last name)
/
/
2.
Provide the following information about the worker's social security credits (coverage) and last place of
residence in the foreign country.
(a) Use columns (1) - (5) to enter information about the worker's periods of employment or self-employment
in the foreign country. (If additional space is required, enter the information in Remarks -- item 19.)
(1) Dates
(2) Name and Address of employer or
(3) Type of Industry
(4) Social Insurance
(5) Name of Agency to which
Worked
self-employment activity
or business
Number used
contributions paid
(From - To)
while working
(b) Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social
insurance system which are not based on employment or self-employment (e.g., coverage for voluntary
contributions, deemed or equivalent coverage, periods of military service, illness, etc.)
(1) Dates
(3) Social Insurance Number used
(4) Name of Agency to which
(2) Type of coverage
Covered
for this coverage if different
contributions paid (if any)
(From - To)
than shown in item 2(a)(4)
(c) Enter the worker's last place of residence in the foreign country:
(City and State or Province)
PLEASE REMOVE PAGE 1 OF THIS FORM BEFORE COMPLETING THE REST OF THE APPLICATION. AFTER APPLICATION IS
COMPLETED AND SIGNED, STAPLE DETACHED PAGE TO APPLICATION.
Form SSA-2490-BK (4-2004) EF (4-2004) (Formerly SSA-2490-F4)
Destroy Prior Editions
Page 1
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0448
APPLICATION FOR BENEFITS UNDER A U.S.
(Do not write in this space)
INTERNATIONAL SOCIAL SECURITY AGREEMENT
If the worker is living, this application should be completed by or on behalf of the worker. If
the worker is deceased, this application should be completed by one of the worker's survivors
who is claiming benefits under the provisions of the international social security agreement.
PART I
Complete Part I in all cases.
1.
(b) U.S. Social Security Number
(a) Print name of worker (First name, middle initial, last name)
/
/
2.
Provide the following information about the worker's social security credits (coverage) and last place of
residence in the foreign country.
(a) Use columns (1) - (5) to enter information about the worker's periods of employment or self-employment
in the foreign country. (If additional space is required, enter the information in Remarks -- item 19.)
(1) Dates
(2) Name and Address of employer or
(3) Type of Industry
(4) Social Insurance
(5) Name of Agency to which
Worked
self-employment activity
or business
Number used
contributions paid
(From - To)
while working
(b) Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social
insurance system which are not based on employment or self-employment (e.g., coverage for voluntary
contributions, deemed or equivalent coverage, periods of military service, illness, etc.)
(1) Dates
(3) Social Insurance Number used
(4) Name of Agency to which
(2) Type of coverage
Covered
for this coverage if different
contributions paid (if any)
(From - To)
than shown in item 2(a)(4)
(c) Enter the worker's last place of residence in the foreign country:
(City and State or Province)
PLEASE REMOVE PAGE 1 OF THIS FORM BEFORE COMPLETING THE REST OF THE APPLICATION. AFTER APPLICATION IS
COMPLETED AND SIGNED, STAPLE DETACHED PAGE TO APPLICATION.
Form SSA-2490-BK (4-2004) EF (4-2004) (Formerly SSA-2490-F4)
Destroy Prior Editions
Page 1
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0448
APPLICATION FOR BENEFITS UNDER A U.S.
(Do not write in this space)
INTERNATIONAL SOCIAL SECURITY AGREEMENT
If the worker is living, this application should be completed by or on behalf of the worker. If
the worker is deceased, this application should be completed by one of the worker's survivors
who is claiming benefits under the provisions of the international social security agreement.
PART I
Complete Part I in all cases.
1.
(b) U.S. Social Security Number
(a) Print name of worker (First name, middle initial, last name)
/
/
2.
Provide the following information about the worker's social security credits (coverage) and last place of
residence in the foreign country.
(a) Use columns (1) - (5) to enter information about the worker's periods of employment or self-employment
in the foreign country. (If additional space is required, enter the information in Remarks -- item 19.)
(1) Dates
(2) Name and Address of employer or
(3) Type of Industry
(4) Social Insurance
(5) Name of Agency to which
Worked
self-employment activity
or business
Number used
contributions paid
(From - To)
while working
(b) Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social
insurance system which are not based on employment or self-employment (e.g., coverage for voluntary
contributions, deemed or equivalent coverage, periods of military service, illness, etc.)
(1) Dates
(3) Social Insurance Number used
(4) Name of Agency to which
(2) Type of coverage
Covered
for this coverage if different
contributions paid (if any)
(From - To)
than shown in item 2(a)(4)
(c) Enter the worker's last place of residence in the foreign country:
(City and State or Province)
Form SSA-2490-BK (4-2004) EF (4-2004) (Formerly SSA-2490-F4)
Destroy Prior Editions
Page 2
I apply for all benefits for which I am eligible under the provisions of the
Name of country
3.
social security agreement between the United States and
This application may be used to claim benefits from the U.S. and/or the foreign country shown in item 3. Check
4.
(X) the block(s) indicating the type of benefit(s) for which you are applying under the country(ies) from which
you are claiming the benefit(s).
BENEFIT CLAIMED FROM FOREIGN COUNTRY
Type of Benefit Claimed From Foreign Country:
Retirement/Old-Age
Survivors
None
Other
Disability or Sickness/Invalidity
(Specify)
BENEFIT CLAIMED FROM THE UNITED STATES
(a) Are you presently receiving benefits from the United States?
Yes
No
(If "No" answer
(If "Yes" answer
(c) below.)
(b) below.)
(b) If you are already receiving U.S. benefits, do you wish to file for a
Yes
No
different type of U.S. benefit?
(If "No" go on
(If "Yes" answer
to item 5.)
(d) below.)
(c) If you are not presently receiving U.S. benefits, do you wish to file
Yes
No
for U.S. benefits at this time?
(If "No" go on
(If "Yes" answer
(d) below.)
to item 5.)
(d) Indicate the type of benefit you wish to claim from the United States:
Retirement
Disability
Survivors
INFORMATION ABOUT THE WORKER
(a) Print worker's name at birth, if different from item 1(a)
5.
(b) Check (X) one for the worker
(c) Enter worker's social insurance number in the foreign country if
different than shown in items 2(a)(4) or 2(b)(3)
Male
Female
(d) If the worker's Social Security number in either the United States or the foreign country is not known,
enter the worker's parents' names:
Mother's name (First name, middle initial, last name, maiden name)
Father's name (First name, middle initial, last name)
(e) Enter the worker's citizenship (Enter name of country)
Do you want this application to protect an eligible spouse's and/or
6.
Yes
No
child's right to Social Security benefits?
(a) Was the worker or any other person claiming benefits on this
7.
Yes
No
application a refugee or stateless person at any time?
(If "Yes" answer
(If "No" go on
(b) below.)
to item 8.)
(b) If "Yes" enter the following information about the person:
Name
Dates of refugee or stateless status
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 3
PART II
Complete Part II ONLY if you are claiming benefits from a foreign country.
If you are applying for sickness or disability/invalidity benefits, enter the
8.
Date
(Month, day , year)
date you became disabled. Otherwise enter ''N/A.''
9.
(a) If you are applying for retirement/old-age benefits, have you stopped
Yes
No
or do you plan to stop working?
(If "No" go on
(If "Yes" answer
to item 10.)
(b) below.)
(b) If ''Yes,'' enter the date you stopped or plan to stop working.
Date
(Month, day , year)
(a) Are you applying for foreign social security benefits under a special
10.
Yes
No
system that covers a specific occupation (e.g., miners, seamen,
(If "No" go on
(If "Yes" answer (b)
farmers)?
to item 11.)
and (c) below.)
(b) What was your occupation in the foreign country?
(c) Did you perform the same type of work in the U.S?
Yes
No
INFORMATION ABOUT THE APPLICANT
Complete item 11 ONLY if you are not the worker. If you are the worker, leave this question blank and go on to
item 12.
(b) What is your relationship to the
(a) Print your name (First name, middle initial, last name, maiden name)
11.
worker?
(c) Enter your U.S. Social Security number
(d) Enter your social insurance number in the
foreign country
(if none or unknown, so
indicate)
ADDITIONAL INFORMATION ABOUT THE WORKER
(a) Enter worker's date of birth (Month, day, year)
(b) Enter worker's place of birth (City, state, province,
12.
country)
If the worker is deceased, enter the
13.
(a) Date (Month, day, year)
(b) Place (City, state, province, country)
date and place of death
(a) Was the worker in the active military or naval service of the
14.
Yes
No
U.S. (including U.S. reserve or U.S. National Guard active
duty for training) or a foreign country after September 7,
(If "No"go on
(If "Yes" answer (b)
1939?
to item 15.)
thru (c) below.)
Dates of Service
(b) Enter the name of country served
Country
and dates of service:
FROM:
TO:
(Month, day , year)
(Month, day , year)
(c) Has anyone (living or deceased) received, or does anyone expect to
Yes
No
receive, a benefit from any U.S. Federal agency based on the worker's
(If "Yes" answer (d)
(If "No" go on
military or naval service?
below
to item 15
(d) If ''Yes'' enter the following information for each person:
(If additional space is required, enter the information in
Remarks -- item 19)
Name
U. S. Agency
Claim No.
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 4
(a) During the past 24 months, did the worker engage in employment or
15.
Yes
No
self-employment covered by the U.S. Social Security system?
(If "Yes" answer
(If "No" go on
(b) and (c) below.)
to item 16.)
List the periods of work covered by the U.S. Social Security system and the name and address of the
employer or self-employment activity
(b) Name and address of employer or self-employment
Work Began
Work Ended
activity
(Month-Year)
(Month-Year)
(c) May we ask any employer listed above for wage information needed
Yes
No
to process this claim?
INFORMATION ABOUT DEPENDENTS FOR WHOM BENEFITS ARE CLAIMED
(a) Are there any children of the worker who are now, or were
16.
Under age 18
Yes
No
in the past 12 months, unmarried and:
OR
Age 18 or over and a
Yes
No
student or disabled
If either block is checked "Yes", enter the information for each child. NOTE: Children include natural children,
step-children and adopted children plus grandchildren living in the same household as the worker.
(c) Relationship to
(d) Sex
(e) Date of birth
(b) Name of child
worker
(M or F)
(Month, day, year)
The spouse, widow or widower of the worker may be eligible for a benefit. In addition, a former spouse of
17.
the worker may be eligible as a divorced spouse, widow or widower. Provide the following information about
any spouse or former spouse of the worker.
SPOUSE
FORMER SPOUSE
FORMER SPOUSE
(a) Name (including
maiden name)
(b) Date of Birth
(Mo., day, yr.)
(c) Date of Marriage
(Mo., day, yr.)
(d) Date of Divorce
(if any)
(Mo., day, yr.)
(e) Country of
Citizenship
(f) Social Insurance
Number in
foreign country
(g) U. S. Social
Security Number
(if any)
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 5

Download Form SSA-2490-BK Application for Benefits Under a U.S. International Social Security Agreement

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