Form SSA-2010-F6 Questionnaire About Special Veterans Benefits

Form SSA-2010 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0782

Statement for Determining Continuing Entitlement for
Special Veterans Benefits (SVB)
FOR SSA USE ONLY
Date Sent
Date Received
Processing Office/Reviewer
Please answer the questions on this form as completely as possible. If you are filling out this form for
someone else, answer the questions as they apply to that person.
1. Name of Beneficiary
Social Security Number
Residence Address of the Beneficiary

2. Name of Representative Payee (if applicable)

Social Security Number

3. Is the Beneficiary deceased?
Yes
No

If beneficiary is deceased, go to last page, sign, date, and
provide your information as requested.

Date of Death
Go to question 4.

4. Since you first began receiving Special Veteran's Benefits, have you returned to the United States for
longer than a full calendar month?
If you had a benefit review in the past, provide the information since the last review.
Yes
No

Go to 4A.
Go to question 5.

A. Provide the dates which you were in the United States for longer than a full calendar month. Be as
detailed as possible, providing at a minimum the month and year that you were in the United States.
FROM
MM-DD-YYYY

TO
MM-DD-YYYY

Form SSA-2010 (XX-XXXX)

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5. Have you ever been deported or been removed from the United States?
Yes
No

Date of deportation or removal
Go to question 6.

6. Are you receiving income other than SVB?
Yes
No

Go to question 7.
Go to page 3.

7. Provide the source and amounts of your benefit income since you began receiving SVB.
If you had a benefit review in the past, provide the information since the last review.
List the source and amount separately in chronological order. If you receive additional income in foreign
currency, please list the type and amount of foreign currency. Please attach evidence of all reported
income. use the remarks section if you need additional space. Do not list any Social Security payments. List
any earned income, pensions or other income you may be receiving.

Source of benefit
income

Amount of income
and currency type

FROM
MM-DD-YYYY

TO
MM-DD-YYYY

Form SSA-2010 (XX-XXXX)

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REMARKS SPACE: You may use this space for any explanations. If you need more space, attach a
separate sheet of paper. If you are continuing an answer to a question, please write the number of the
question first.

IMPORTANT: Anyone who knowingly makes or causes to be made a false statement or
representation of material fact for use in determining a payment under the Social Security Act, or
knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right
to payment, or submits or causes to be submitted any false statement or document knowing the
same to contain any misrepresentation of material fact, commits a crime punishable under Federal
law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Form SSA-2010 (XX-XXXX)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 808 and 810 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent an accurate and timely decision on your claim, and could result in the loss of some payments.
We will use the information you provide to determine if you are entitled to continued Special Veteran’s
Benefits and the correct payment amount. We may also share your information for the following purposes,
called routine uses:
• To representative payees, when the information pertains to individuals for whom they serve as
representative payees, for the purpose of assisting SSA in administering its representative payment
responsibilities under title VIII and assisting the representative payees in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they serve as
payees; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at
84 FR 58422; 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as
published in the FR on January 11, 2006, at 71 FR 1830; and 60-0273, entitled Social Security Title VIII
Special Veterans Benefits Claims Development and Management Information System, as published in the
FR on March 14, 2000, at 65 FR 13803. Additional information, and a full listing of all our SORNs, is
available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget (OMB) control number. We estimate that it will take about 20 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-2010 (XX-XXXX)

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REPORTING INSTRUCTIONS FOR SPECIAL BENEFITS FOR WORLD WAR II VETERANS
You must report to the Social Security Administration if:
•
•
•
•
•

•
•
•
•

You change your mailing address or residence.
You return to or visit the United States for a calendar month or longer.
You become unable to manage your benefits.
You have been deported or removed from the United States.
You have an unsatisfied warrant for your arrest for a felony crime in the United States, or in U.S.
jurisdictions that do not define crimes as felonies, for a crime that is punishable by death or
imprisonment for a term exceeding one year.
You are in violation of a condition of probation or parole.
You receive an increase or decrease in a pension, annuity or another recurring payment. Some
examples of payments are retirement, workers' compensation, veterans' benefits, or disability benefits.
You move to another country.
Your family, representative payee or other knowledgeable person must notify the Social Security
Administration if you die.

HOW TO REPORT
If you are outside the United States and have questions or have changes to report, you may contact one of
the offices shown below.
• If you live in the Philippines, please call the Social Security Administration at: 632-301-2000 Ext. 9
from 8 a.m. to 3 p.m., Monday through Friday. You may write or visit the Social Security
Administration, 1201 Roxas Blvd., Ermita 0930 Manila. You also may e-mail the Social Security
Administration in Manila, Philippines at: FBU.Manila@ssa.gov
• If you live in American Samoa, Canada, Guam, Puerto Rico, Samoa or the Virgin Islands, contact the
nearest U.S. Social Security office.
• If you live in Mexico, contact the nearest U.S. Social Security office or the nearest U.S. Embassy
or consulate.
If you live in any other country, contact the nearest U.S. Embassy or consulate. Visit
www.socialsecurity.gov/foreign for a complete list of these offices.
If you are in the United States and have questions, you may visit our website at www.socialsecurity.gov or
call us toll-free at 1-800-772-1213. We can answer specific questions from 7 a.m. to 7 p.m., Monday
through Friday. We can provide information by automated phone service 24 hours a day.