Form SSA-2512 Pre-1957 Military Service--Federal Benefit Questionnaire

SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OM6 NO. O9W-0120

TOE 420

PRE-1957 MILITARY SERVICE

-- FEDERAL BENEFIT QUESTIONNAIRE

PRIVACY ACTiPAPERWORK ACT NOTICE: The Social Sss-an, Admmlsvat#onis amhwizod to sd-t th. Inlorm.tion on this 1under s.suon
217 of the Socoal Security Act. as amend- bl 42 4.S.C 417 Tn. Informatfon is n r d . d to es1.bll.h wh0th.r the W.Q.
.am's mtllury w l s . m y b.
o.rabls. Your - r
to h)*rsauan
r
is volumarv. howava. l a l u a to
used to dstermtne enulemmt to or tns amount of anv Social S.cunN
provide all or p n t of this infamalion could result in the ioss of swne b . k f i u or 1hsu;uu eovrage.~Althoughtk. inibrmauon on this
Is nrdy used for
any prrposs other than stated edvbavs, them io 1 posribilky dut In the admlnlstratlon of Uu Sosl.1 Snudly p w n m r w b the ~dminlstntimof prognmr
requiting cowdimion with the Social Snurity Administration. information mayb. dlrelored as fdlowr: To the b n w h of Uu mlllury you sewed in, or to the
Veterans Adminirtrsuon or other Federal sponsy as requ1r.d t o determine if the military -1may b. used for Social Snudty puwwl, to comply with
Fadaal laws which require the rdeaga of information hom Smid Seeutity r-d%
and m facilluts sutlsdcal research ad d n r t k i t i e s Nad.d to sssum
the integrity a d improveman of du

im

NAME OF WAGE FARNER IFlRST NAME. MIDDLE INITIAL. LAST NAME)

SOCIAL 8LCURTY NUMBER

NAME USED IN SERVICE (IF DIFFERENT FROM ABOVE1

SERVICE NUMBER

PART I. MILITARY SERVICE HISTORY

- PRIOR TO 1957

Enter the month. day. and year of any active or reserve military service during the period September 18.
1940 through December 31, 1956. If the service BEGAN BEFORE OR ENDED AFTER this period, show the
starting or ending date even though it is outside the period.
1.

-

ACTIVE DUTY REGULAR AND ACTIVE RESERVE SERVICE
Enter information about REGULAR ACTIVE DUTY of any duration and about RESERVE ACTIVE
SERVICE of 9 0 consecutive days or more while on active duty or active duty for training.
DATE ACTIVE DUN
BEGAU

IAL WANCH OF SERVICE

DAY

,

.. --.
..-.. --

..--

I

DATE SEPARATED
FROM ACITNE DUN

YEAR

D l DATE MEWRSHlP

ID) RATE OR
RANK

ICI

MONTH

I

DAY

YEA#

ICI DATE MEMBERSHIP

I

ID1 RATE OR

PART II. MILITARY RETIREMENT INFORMATION

3. 1(a)
(b)

Not retired /If checked, go on to Part I
l
l
)
Retired

{

(If veteran is giving information complete (01and id1below.
(If survivor o f veteran is giving information go on to Part 1111

(c) Basis for retirement (Complete even if not receiving pay1

I

Disability

Length of service
Reserve service

-- Payable at age 8 0
IS] Basis unknown

Other

(d) Did you waive all or part of your retirement pay as a condition to receive veterans' administration
disability compensation or t o receive "civil service* (Office of Personnel Management) or other
yes
NO
Federal agency credit for your military service?
Form SSA-2612 (4-1984) EF (11-2000)

(Over)

PART Ill.CIVILIAN FEDERAL AGENCY BENEFIT INFORMATION
(Including Veterans Administration1
4.

(a1 Have you ever been, or do you expect to be, entitled t o receive a civilian Federal benefit?
No (If "no', omit the remaining questions and sign below.)
Yes
(bl Please check type of benefit that you are receiving, were receiving, or that you expect t o
receive.
Age or length of service
Disability

-

U Other

( U Survivor
5.

]la) Name of Federal agency that was, is now, or will be paying benefit:

I

Office of Personnel Management (Formerly Civil Service Commission)

[7

Veterans' Administration (Check only if receiving benefits because o f waiving all or part o f
military retirement payl
Office of Workers Compensation Programs (Check only if receiving benefits because o f
waiving all or p a n of another Federal benefit)
SpecifV in remarks the agency and the type of benefit waived.
Other (Specify)

(bl Years of civilian Federal
employment

6.

(cJ Date claim filed

(dl Federal Benefit claim number

MOST RECENT Federal employer:
(a1 Name of agency (if different from 5(a) above)
(bl City and State where employed

I c l Date last worked
I

REMARKS: /You may uae this space for any explanations. If you need more space, attach a separate sheer.]

.

I know that anyone who makes or causes to be made a false statement or representation of material fact in an
application or for use in determining a right to payment under the Social Security Act commits a crime punishable under
Federal law bv fine, im~risonmentor both. I affirm that all information I have given
in this document is true.
SIGNATURE OF APPLICANT
Signature /First name, middle inirial, lest name1 (Write in ink1
l~ate
(Month, day, year1
Telephone Number l;nclude area code1

HERE
Mailing Address /Number and street, Apt. No., P.O. Box, or Rural Route)
City and State

lZlP Code
I

Witnesses are required ONLY if this application has h e n signed by mark IXI above. If signed by mark (XI, two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness
2. Signature of Witness
I

Address (Number and street, City, Stare and ZIP Code1

Form SSA-2512 14-1984) EF (1 1-2000)

Address (Number and streel, City, Slate and ZIP Code/

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Paverwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send&o comments relating to our time estimate to this
address, not the completed form.