SSA-2 MCS Signature Proxy

FACSIMILE: APPL - RSDHI CLAIMS APPLICATION
MCS TRANSFER TO: XXXX RSDHI CLAIMS APPLICATION
APPL
[1-M]
NH NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX XXXX
[2-M]
[3-M]
SSN: SSSSSSSSS SEX: X
NH BIRTHDATE: 99999999
[4-M]
[5-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[6-M]
SELECT CLAIM TYPE(S): 9 9 9 1. RETIREMENT 4. AUXILIARY
7. AGE 72
2. DISABILITY 5. UNINS MED ONLY 8. ESRD
[7-C]
3. SURVIVOR 6. LUMP SUM
ABBREVIATED APPLICATION: X
CLAIMANT (IF DIFFERENT)
[8-C]
NAME: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
[9-C]
[10-C]
[11-C]
SSN: 999999999 SEX: X
BIRTHDATE: 99999999
[12-C]
[13-C]
PROOF (A/B/C/F/Q): X
PROOF TYPE (P/H/N/O): X
[14-C]
[15-C]
RELATIONSHIP TO NH: 9 1. SPOUSE
(SUBSEQUENT CLAIM: 9 ) 1. RIB
2. SPOUSE WITH CHILD IN CARE
2. DIB
3. CHILD
APPLICANT (IF DIFFERENT) 4. DEPENDENT PARENT
[16-C]
NAME:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
[18-C]
[19-C]
SSN: 999999999 EIN: 999999999 WILL APPLICANT BE ENTERED IN RPS (Y/N):
X

FACSIMILE: ADDB - ADDITIONAL BENEFITS
mcs
TRANSFER TO: XXXX
ADDITIONAL BENEFITS
ADDB
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939
(Y/N): X
[2-M]
[3-C]
WORKED IN RR FOR 5 YEARS OR MORE (Y/N): X
SPOUSE (Y/N):X
[4-M]
[5-C]
RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X
SPOUSE (Y/N): X
[6-M]
[7-C]
COVERED UNDER FOREIGN SSA (Y/N): X
COUNTRY: XXXXXXXXXX IF
COVERED
[8-C]
[9-C]
FILING FOR FOREIGN SSA (Y/N): X
REQUIRES FOREIGN QC'S FOR US
FILING (Y/N): X
[10-C]
[11-C]
SPOUSE COVERED UNDER SSA OF OTHER COUNTRY (Y/N): X
COUNTRY:
XXXXXXXXXX
[12-M]
[13-C]
CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X
SPOUSE (Y/N):
X
[14-M]
[15-C]
JAPANESE INTERNEE (Y/N): X
VOW OF POVERTY (Y/N):
[16-M]
QUALIFY FOR US FED/STATE/LOCAL GOVT PENSION BASED ON ANY WORK
YOU PERFORMED
which was NOT COVERED UNDER SSA (Y/N): x
[17-M]
CURRENTLY ENTITLED TO A PENSION NOT COVERED UNDER SSA (Y/N): X
[18-C]
IF NO, DO YOU EXPECT TO BE ENTITLED TO A PENSION NOT COVERED UNDER
SSA IN THE FUTURE
(Y/N): X
[19-C]
IF YES, SHOW FUTURE ENTITLEMENT DATE (MMYY): 9999
[20-M]
CLAIMANT HAS CHILD OF NH IN CARE(Y/N): X
[21-C]

fILING FOR MEDICARE ONLY, RESTRICTING MONTHLY BENEFITS (Y/N): X
[22-C]
WILL MEDICARE APPLY: 9 1. YES 2. NO 3. ALREADY ENROLLED ON ANOTHER
SSN
[23-M]
IF CLAIMANT IS FILING AS A SURVIVING SPOUSE, IS CLAIMANT
FILING FOR BENEFITS ON OWN RECORD (Y/N): X

FACSIMILE: ADDR - APPLICANT MAILING ADDRESS
MCS TRANSFER TO: XXXX APPLICANT MAILING ADDRESS
ADDR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
APPLICANT NAME:
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
[1-M]
ADDRESS: PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
[2-M]
[3-C]
[4-C]
CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
[5-C]
[6-C]
STATE & COUNTY CODE: PPPPPP COUNTY: XXXXXXXXXXXXXXX
[7-C]
[8-C]
COUNTRY: PPPPPPPPPPPPPPPPPPPPPP
CONSUL CODE: PPP
[9-C]
foreign POSTAL ZONE: PPPPPPPPPPPPPPP
[10-C]
address explanation:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
[11-C]
[12-C]
Domestic Phone: XXXXXXXXXX
foreigh phone: xxxxxxxxxxxxxxx
[13-C]
enter phone code: x 1= home 2=work 3=none 4=unk 5=other 6=attorney 7=mobile
transfer to: PPPP

FACSIMILE: CLMR - CL MILITARY RETIREMENT/FEDERAL BENEFIT
MCS 2.5 TRANSFER TO: XXXX CL MILITARY RETIREMENT/FEDERAL
BENEFIT
CLMR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
IF RETIRED FROM MILITARY, BASIS OF RETIREMENT: 9
1. LENGTH OF SERVICE
3. RESERVE SERVICE PAYABLE AT AGE 60
2. DISABILITY
4. OTHER
[2-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[3-C]
IF RETIRED AND SERVICE AFTER DEC 31, 1956, INDICATE BRANCH OF
SERVICE PAYING
BENEFIT: 9
1. ARMY
5. COAST GUARD
2. NAVY
6. PUBLIC HEALTH SERVICE
3. AIR FORCE
7. COASTAL/GEODETIC SURVEY
4. MARINE CORPS
8. OTHER
[4-C]
IF OPTION 8 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[5-C]
WAIVED ALL/PART OF RETIREMENT TO GET VA OR OTHER FED CREDIT (Y/N):
X
[6-C]
IF ELIGIBLE FOR CIVILIAN FEDERAL AGENCY BENEFITS, INDICATE BENEFIT
TYPE: 9
1. SERVICE 2. SURVIVOR 3. DISABILITY 4. OTHER
[7-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[8-C]
NAME OF FED AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[9-C]
[10-C]
[11-C]
YEARS EMPLOYED: 99 DATE CLAIM FILED: 999999 CLAIM NO.:
XXX999999999
[12-C]
MOST RECENT AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[13-C]
[14-C]
[15-C]
CITY: XXXXXXXXXXXXX STATE: XX LAST WORKED: 999999

FACSIMILE: CLMS - CL MILITARY SERVICE PAGE 1
MCS
CL MILITARY SERVICE
CLMS
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
[2-C] [3-C]
FIRST NAME USED IN SERVICE: XXXXXXXXXX MI: X LAST NAME:
XXXXXXXXXXXXXXXXXXX
[4-C]
SERVICE NO: XXXXXXXXX
[5-M]
*RECEIVE OR ELIGIBLE FOR MIL OR CIV FEDERAL AGENCY BENEFIT (SELECT
ONE): x
1=CIVILIAN 2=MILITARY 3=BOTH 4=NONE.
[6-C] [7-C]
[8-C] [9-C] [10-C] [11-C]
[12-C]
[ A/R BRANCH OF SERVICE START END N/E RANK
PROOF
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
[13-C] [14-C]
[15-C] [16-C]
[JAPANESE INTERNEE START END
PROOF HOURLY WAGE
|
999999 999999
X
99999999
|
999999 999999
X
99999999
[17-C]
PF1 FOR HELP MORE (Y/N): X
PAGE: 1
TRANSFER TO: XXXX

FACSIMILE: CLRR - CL RAILROAD EMPLOYMENT
MCS 2.5 TRANSFER TO: XXXX CL RAILROAD EMPLOYMENT
CLRR
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSN: SSSSSSSSS
[1-C]
[2-C]
[3-M]
MONTHS WORKED IN RR AFTER 1936: 999 BEFORE 1937: 999 LAST 18 MOS
(Y/N): X
[4-M]
[5-C]
EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX
[6-C]
IF EMPLOYEE LIVING, REC'D RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS
(Y/N): X
[7-C]
IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS
(Y/N): X
[8-C]
EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X
IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS
BENEFITS:
[9-C]
RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[10-C]
WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[11-C]
DEPT+OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF CLAIMANT EVER RECEIVED RRB BENEFITS:
[12-C]
RR APPLICANT: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO:
XXXXXXXXXXX
[13-C]
[14-C]
RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN:
999999999
[15-C]
RELATIONSHIP: XXXXXXXXXX
[16-C]
BENEFIT TYPE: 9 SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL
[17-C]
HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY
ENTITLEMENT TO
SOCIAL SECURITY BENEFITS (Y/N): X

FACSIMILE: DECD - INFORMATION ABOUT THE DECEASED
MCS TRANSFER TO: XXXX INFORMATION ABOUT THE DECEASED
DECD
NH SSSSSSSSS
SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
[2-M]
[3-C]
DATE OF DEATH: 99999999 PROOF (P/N): X TYPE OF PROOF (P/O): X
[4-M]
DOMICILE AT DEATH: XXXXXXXXXXXXXXX
[5-M]
PLACE OF DEATH (CITY/STATE): XXXXXXXXXXXXXXX
[6-M]
[7-C]
DISABLED AT TIME OF DEATH (Y/N): X
DISABILITY BEGAN: 999999
[8-C]
WAS CLAIMANT ELIGIBLE AS WIDOW(ER) PRIOR TO 1985 ON ANY SSN (Y/N): X
[9-C]
SURVIVING SPOUSE (Y/N): X
[10-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[11-C]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
[12-C]
SPOUSE LIVING WITH DECEASED AT TIME OF DEATH (Y/N): X
[13-C]
[14-C]
AWAY FROM HOME: 9
1. DECEASED
DATE LAST HOME: 999999
2. SPOUSE
[15-C]
REASON FOR SEPARATION AT DEATH:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[16-C]
IF DUE TO ILLNESS, NATURE OF ILLNESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXX
[17-C]
REASON ABSENCE BEGAN:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[18-C]
IS SPOUSE: 9 1. LIVING IN SAME HOUSEHOLD 2. ELIGIBLE OR ENTITLED TO
BENS
3. NOT ENTITLED TO LSDP
FACSIMILE: DEME - WORK DEDUCTIONS/ELECTION OPTION

MCS 3.6 TRANSFER TO: XXXX

WORK DEDUCTIONS/ELECTION OPTION
DEME
SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS

NH SSSSSSSSS
SSSSSSSSSS
LIST TYPES, AMOUNTS, PRFS, AND NON-SERVICE MONTHS FOR SSSS SSSS
SSSS
TYPES ARE: 1=WAGES 2=SEI 3=WAGES AND SEI PRF: P=PERM
NON-SERVICE MONTHS PLACE AN X UNDER ALL, NONE, OR EACH MONTH
THAT APPLIES
[1-C] [2-C] [3-C]
[4-C] [5-C]
YEAR TYPE AMOUNT ALL NONE 01 02 03 04 05 06 07 08 09 10 11 12 PRF FY
ENDS
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
SS S SSSSSSSSS X X X X X X X X X X X X X X X 99
[6-M]
IF OVER MAX OR NONCOVERED EARNINGS INVOLVED, CORRECT ABOVE
AMOUNTS
[7-M]
SPECIAL PAYMENTS INVOLVED (Y/N): X IF YES, CORRECT ABOVE
[9-C]
[8-C]
FOREIGN WORK SERVICE MONTHS
(YY) ALL 01 02 03 04 05 06 07 08 09 10 11 12
99
X
X X X X X X X X X X X X
99
X
X X X X X X X X X X X X
99
X
X X X X X X X X X X X X
[10-M]
[11-C]
ELECTION/ENTITLEMENT OPTION: X DATE(MMYY): 9999
A. MOST ADVANTAGEOUS MONTH
B. EARLIEST MONTH WITHOUT
REDUCTION
C. CLAIMANT'S CHOSEN MONTH
D. UNREDUCED CLAIMANT
E. NOT APPLICABLE (DIB AUX SPOUSE WHO MEETS CRITERIA)
F. OTHER: SPECIAL REASON
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

FACSIMILE: DEPC - DEPENDENT CHILDREN OF NH
MCS 2.5 TRANSFER TO: XXXX DEPENDENT CHILDREN OF NH
DEPC
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS
LIST ALL CHILDREN OF NH: UNDER 18
18-19 AND ATTENDING SECONDARY SCHOOL
[1-M]
DISABLED/HANDICAPPED PRIOR TO 22
NAME:
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX

FACSIMILE: EARN - EARNINGS
MCS
EARNINGS
EARN
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
LIST ALL EARNINGS AND TYPES FOR SSSS SSSS SSSS
EARNINGS TYPES ARE:1=FICA WAGES 2=SEI 3=EMPLOYEE REPORTED TIPS
4=RR LAG.
PROOF CODES ARE: P=PROVEN R=READILY AVAILABLE N=NOT AVAILABLE
D=DELETED LAG.
[1-C] [2-C] [3-C] [4-C]
[EARNINGS
YEAR TYPE AMOUNT PROOF
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
|
99 9 9999999.99 X
[5-C]
COMPUTE BENEFITS AND COMPLETE CLAIM WITHOUT LAG EARNINGS (Y/N): X
TRANSFER TO :XXXX

FACSIMILE: NHAB - NH ADDITIONAL BENEFITS
MCS 2.7 TRANSFER TO: XXXX NH ADDITIONAL BENEFITS
NHAB
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
ACTIVE U.S. MILITARY/RESERVE/NATL GUARD SERVICE AFTER SEPT 7 1939
(Y/N): X
[2-M]
WORKED IN RR FOR 7 YEARS OR MORE (Y/N): X
[3-M]
RECEIVING RR RETIREMENT PENSION/ANNUITY (Y/N): X
[4-M]
[5-C]
[6-C]
COVERED UNDER FOREIGN SSA (Y/N): X COUNTRY: XXXXXXXXXX IF
COVERED,
[7-C]
FILING FOR FOREIGN SSA (Y/N): X REQUIRES FOREIGN QC'S FOR US FILING
(Y/N): X
[8-M]
CIVILIAN EMPLOYEE OF FEDERAL GOVT IN JAN 1983 (Y/N): X
[9-M]
[10-M]
JAPANESE INTERNEE (Y/N): X
VOW OF POVERTY (Y/N): X

FACSIMILE: NHID - NH IDENTIFICATION
MCS
TRANSFER TO: XXXX NH IDENTIFICATION
NHID
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
EVER MARRIED (Y/N): X
[2-M]
child under 18, student 18 to 19, 18 or older and disabled before 22 (y/n): x
[3-M]
NH DEP PARENTS (Y/N): X
[4-M]
WORK LAST YEAR OR THIS YEAR (Y/N): X
[5-M]
[6-M]
[7-M]
PRIOR APPLICATION FOR RSDI (Y/N): X FOR SSI (Y/N): X FOR MEDICARE (Y/N):
X
[8-C]
[9-C]
CROSS REFERENCE SSN: 999999999 STAT: XX SSN: 999999999 STAT: XX
[10-C]
[11-C]
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
SSN: 999999999
NH NAME IN PRIOR APPLICATION: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
SSN: 999999999
[12-C]
MULTIPLE SSN: 999999999 999999999 999999999 999999999 999999999
[13-C]
OTHER NAMES: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX

FACSIMILE: NHMR - NH MILITARY RETIREMENT/FEDERAL BENEFIT
MCS 2.5 TRANSFER TO: XXXX NH MILITARY RETIREMENT/FEDERAL
BENEFIT
NHMR
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
IF RETIRED FROM MILITARY, BASIS OF RETIREMENT: 9
1. LENGTH OF SERVICE
3. RESERVE SERVICE PAYABLE AT AGE 60
2. DISABILITY
4. OTHER
[2-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[3-C]
IF RETIRED AND SERVICE AFTER DEC 31, 1956, INDICATE BRANCH OF
SERVICE PAYING
BENEFIT: 9
1. ARMY
5. COAST GUARD
2. NAVY
6. PUBLIC HEALTH SERVICE
3. AIR FORCE
7. COASTAL/GEODETIC SURVEY
4. MARINE CORPS
8. OTHER
[4-C]
IF OPTION 8 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[5-C]
WAIVED ALL/PART OF RETIREMENT TO GET VA OR OTHER FED CREDIT (Y/N):
X
[6-C]
IF ELIGIBLE FOR CIVILIAN FEDERAL AGENCY BENEFITS, INDICATE BENEFIT
TYPE: 9
1. SERVICE 2. SURVIVOR 3. DISABILITY 4. OTHER
[7-C]
IF OPTION 4 CHOSEN, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXX
[8-C]
NAME OF FED AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[9-C]
[10-C]
[11-C]
YEARS EMPLOYED: 99 DATE CLAIM FILED: 999999 CLAIM NO.:
XXX999999999
[12-C]
MOST RECENT AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[13-C]
[14-C] [15-C]
CITY: XXXXXXXXXXXXX STATE: XX LAST WORKED: 999999

FACSIMILE: NHMS - NH MILITARY SERVICE
MCS
NH MILITARY SERVICE
NHMS
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS
SSSSSSSSSS
FIRST NAME USED IN SERVICE: XXXXXXXXXX MI: X LAST NAME:
XXXXXXXXXXXXXXXXXXX
SERVICE NO: XXXXXXXXX
*RECEIVE OR ELIGIBLE FOR MIL OR CIV FEDERAL AGENCY BENEFIT (SELECT
ONE): 9
1=CIVILIAN 2=MILITARY 3=BOTH 4=NONE
[ A/R BRANCH OF SERVICE START END N/E RANK
PROOF
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
| X XXXXXXXXXXXXXXXXX 999999 999999 X XXXXXXXXXXXXXX XXX
IS DEVELOPMENT OF VA SURVIVOR PENSION REQUIRED (Y/N): X
[JAPANESE INTERNEE START END
PROOF HOURLY WAGE
|
999999 999999
X
99999999
|
999999 999999
X
99999999
PF1 FOR HELP

MORE (Y/N): X

PAGE: 1

TRANSFER TO: XXXX

FACSIMILE: NHRR - NH RAILROAD EMPLOYMENT
MCS 2.5 TRANSFER TO: XXXX NH RAILROAD EMPLOYMENT
NHRR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS SSN: SSSSSSSSS
[1-C]
[2-C]
[3-M]
MONTHS WORKED IN RR AFTER 1936: 999 BEFORE 1937: 999 LAST 18 MOS
(Y/N): X
[4-M]
[5-C]
EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX
[6-C]
IF EMPLOYEE LIVING, RECD RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS
(Y/N): X
[7-C]
IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS
(Y/N): X
[8-C]
EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X
IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS
BENEFITS:
[9-C]
RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[10-C]
WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[11-C]
DEPT + OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF CLAIMANT EVER RECEIVED RRB BENEFITS:
[12-C]
RR APPLICANT: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO:
XXXXXXXXXXX
[13-C]
[14-C]
RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN:
999999999
[15-C]
RELATIONSHIP: XXXXXXXXXX
[16-C]
BENEFIT TYPE: 9 SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL
[17-C]
HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY
ENTITLEMENT TO
SOCIAL SECURITY BENEFITS (Y/N): X

FACSIMILE: NMAR - NH MARRIAGE
MCS 3.4
NH MARRIAGE
NMAR
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
[2-C]
[3-M]
SPOUSE''S FIRST NAME: XXXXXXXXXXXXXXX MI: X
LAST NAME:
XXXXXXXXXXXXXXXXXXXX
[4-C]
SPOUSE''S SSN: 999999999
[5-C]
[6-C]
SPOUSE 'S BIRTHDATE (MMDDYYYY): 99999999
IF BIRTHDATE UNKNOWN,
AGE: 999
[7-M]
[8-M]
MARRIAGE DATE (MMDDCCYY): 99999999
PROOF (Y/N): X
[9-M]
[10-M]
MARRIAGE CITY: XXXXXXXXXXXXXXX MARRIAGE STATE/FOREIGN COUNTRY:
XX
[11-C]
SELECT MARRIAGE TYPE: 9
1=CLERGY/PUBLIC OFFICIAL
2=COMMON LAW
3=OTHER CEREMONIAL
4= DEEMED
[12-M]
[13-C]
[14-C]
MARRIAGE ENDED (Y/N): X
MARRIAGE END DATE(MMDDCCYY): 99999999
PROOF (Y/N): X
[15-C]
[16-C]
Marriage ENDED CITY XXXXXXXXXXXXXXX MARRIAGE ENDED STATE OR
FOREIGN COUNTRY: XX
[17-C]
SELECT REASON: 9
1=DEATH
2=DIVORCE
3=ANNULMENT OR VOIDABLE
4=PUTATIVE
5=VOID/VOIDED
[18-C]
IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999
[19-M]
[20-C]
OTHER MARRIAGES (Y/N): X
DELETE SCREEN (Y/N): X
[21-D]
[22-C]
PAGE: s
TRANSFER TO: XXXX

FACSIMILE: NPAR - NH DEPENDENT PARENT
MCS 2.5 TRANSFER TO: XXXX NH DEPENDENT PARENT
NPAR
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
DEPENDENT PARENTS:
[1-M]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[2-M]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
[3-M]
PARENT TYPE: 9
1. NATURAL 2. STEPPARENT 3. ADOPTIVE
[4-C]
IF STEPPARENT, DATE OF STEP-RELATIONSHIP: 999999
[5-C]
IF ADOPTIVE PARENT, DATE OF ADOPTION: 999999
[6-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[7-M]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
[8-M]
PARENT TYPE: 9
1. NATURAL 2. STEPPARENT 3. ADOPTIVE
[9-C]
IF STEPPARENT, DATE OF STEP-RELATIONSHIP: 999999
[10-C]
IF ADOPTIVE PARENT, DATE OF ADOPTION: 999999

FACSIMILE: RMKS - REMARKS
MCS
TRANSFER TO: XXXX REMARKS SCREEN
RMKS
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS
SSSSSSSSSS
[1-C]
TYPE OF REMARKS
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX

[2-C]
MORE (Y/N): X

[3-C]
GO TO RPS (Y/N): X
PAGE S

FACSIMILE: WORK - WORK HISTORY
MCS 3.4 TRANSFER TO: XXXX
WORK HISTORY
WORK
NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS
SSSSSSSSSSSSSSS
[1-M]
EMPLOYED IN 20SS 20SS 20SS 20SS (Y/N): X
[3-C]
[4-C]
[2-C]
MMYY
MMYY
[5-C]
EMPLOYER NAME ADDRESS
START DATE END DATE N/E
1. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999
9999 X
2. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999
9999 X
3. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 9999
9999 X
[6-C]
AUTHORIZATION TO CONTACT EMPLOYERS (Y/N): X
[7-M]
SELF-EMPLOYED IN 20SS 20SS 20SS 20SS (Y/N): X
[8-C]
[9-C]
[10-C]
IF YES, SHOW: YEARS
TYPE OF BUSINESS
NET OVER $400 (Y/N)
99 XXXXXXXXXXXXXXXXXXXXXXXXXXX
X
99 XXXXXXXXXXXXXXXXXXXXXXXXXXX
X
99 XXXXXXXXXXXXXXXXXXXXXXXXXXX
X
99 XXXXXXXXXXXXXXXXXXXXXXXXXXX
X
[11-C]
[12-C]
MORE (Y/N): X
DELETE THIS PAGE (Y/N): X
PAGE: S

FACSIMILE: CADR - CLAIMANT MAILING ADDRESS
MCS
CLAIMANT MAILING ADDRESS
CADR
NH: SSSSSSSSS SSSSS SSSSSSSSSS
CL: SSSSSSSSS SSSSS
SSSSSSSSSS
[1-M]
*ADDRESS 1: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 2:
PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 3: PPPPPPPPPPPPPPPPPPPPPP
ADDRESS 4:
PPPPPPPPPPPPPPPPPPPPPP
[2-M]
[3-C]
[4-C]
*CITY: PPPPPPPPPPPPPPPPPPPPPP
STATE: PP
ZIP: PPPPP
[5-C]
[6-C]
STATE & COUNTY CODE: PPPPP
COUNTY: XXXXXXXXXXXXXX
[7-C]
[8-C]
COUNTRY: PPPPPPPPPPPPPPPPPPPPP
CONSULAR CODE: PPP
[9-C]
FOREIGN POSTAL ZONE: PPPPPPPPPPPPPPP
[10-M]
[11-M]
*bank account (y/n): x
*direct express (y/N): x
[12-C]
[13-C]
DIRECT DEPOSIT ROUTING TRANSIT NUMBER: 999999999
ACCOUNT TYPE
(C/S): A
[14-C]
DEPOSITOR ACCOUNT NUMBER: 99999999999999999
[15-C]
[16-C]
DOMESTIC PHONE: PPPPPPPPPP
FOREIGN PHONE:
PPPPPPPPPPPPPPP
[17-c]
enter phone code: x 1= home 2= work 3=none 4=unknown 5=other 6=attorney
7=mobile