Form SSA-19-F6 Application for Special Age-72-or OVer Monthly Payments

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Om

APPIJCAT10N FOR SPEQAL AGE-72-OR-OVER

MONTHLY PAYMENTS

I

appy far spec:ilil paymanu. ...-.:kIr Sue. 228 of !he SocIal ~ ~ as emanded.. mel f« eMitSeI'rIent to 8n inlUrMCe
be PlY'" ta me under Tille U and part A of TIda XVUI of hit ~ a& pl'tllMlntfv amended.

~ which mav

1.

Errter VlIUI' SodeI Seeurity Number
fII nM8 tN Imknown _ indicllt:ffl

Ent. Ycu FUI Name IFbt nfNIIe, mIdd1ft ~ IM!t lJlIII1lft}

---1--/---­
2.

.

fnIer \/'MIt daw of binh (Show mMtli. by, 1.Ind 'YflII'rl

o

3. W . HlNe

you . . Red an app"!icBtlon for saciilt 81f1Curity bllnefits ftltbt

incIudtIs IIpp1It:tJtion fof ~ iNluranu pro~. . . well as' lor

mt:JIItIJIy usb 1MneIitfIJ1 R "Yes,· 0DII'IIIIeM Cb). (lU. a.'Id (cij below.

Ib) Enter name of ,.non an wl'lOoMl
previaUe flPpIiCBtion{s).

..nne.

record VDU filed

...

Cdl Sil'lCel you fled your pnMOIMI ~I.'tpl_ion(s). I'I4I\fIe yotl bien 1lI8If­
employed 1)1 w~ in CIITIPIoyment ~ by Social Security or 1:he

RailrMd Ftethmn AGtl

II

IJV>ef lfIQ811ed in WGtk that wallo 00V4iII'M ulIIIM' f:IH SOCI~I .writr
of a ouunllY CIIhIr 'lbal'l the Unit.el:l Stat.'1

Have f{JII
&yS$'R

•

tf ·Yss. "'list the coul'ltryl&'):

6.

W. . yeti

~~ or Slllf..emplayed

7.

IMonth, yeM1

I-~--

Dvtr.ll

DNo

Dyes

DNo

Oy.

DNo

II

ttl,.

year or Iut year?

6. If you W$I1Iii in 1he active mllltlrv or new' Slll'Vice attar S~r 7.
FI'M'!

.

Cd E11ter Sadal Seeurt:ty .-.rttber
of penan Aimed In (1:11

YGUI'

---1-

4.

DNo

V.,.

1939. enl« .... 11M=: of IIOI'¥ice below;

To {Monrti• .,...,J

An 'fGU a. reeident of ono of tht 50 St~M of 1he United - . tha

Oistrict of Ccltnbia or Nor1hem Mai.-.a ~.i' ITQ I'eIiIldrI MI . . . .

h1eIiInfi to tMlctt tt/tamtJ
I

"".1

.

o

V••

DNo
{OYer)

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115/2009

Page 1 of 1

8.

ta)

(b)

AnI you a.

dt--. M the United States?

•

(ff "Ye.$,. " gtt on to itam 9J
(If "/Vo... answer fbJ. (cJ. Md Id) below.)

.

",1HlG1 in ttle United

Ova

DNo

Have
_dec:! outside lb. UniMd: Stat.. at iIIl'Iy time duril19 the last
five yearsl
f" "Yes,. • IMlt6lN11ow tIIfI infwrrwtkm ~}

DVlM

DNo

Ale you IlIIwfulv eclmltted far

.,.~

•

""'U

•

DATE AESlDfNCE
8EGAN

ADCIIIiSSES AT WI-ICH YOU FlESlD&:O OUTSIDE. tHE U.s. IN lHE
LA$T fIVe YEARS i6Jlgin Mrh tfl(f lIIQf.t II!CIeIIf NdIe#I
If' yQcr nfIfId RIOr& ~ UH • •~ ....... tN IIllfIIhIN Msn til PftIferJ

VEIIFt

MatlTJI

9. /4r8 you receAling JdlIiG oIISIi.mnca cuh payments or r.JenII Suppllllrwntal

....

Security Incarne P81fI'ents?
{II)

,~

1M.1E RESIDENCE
&MDIiD

MOWTM

YEA"

•

fel N.-ne the country c1 wHch ygU 011"' a dlimn: .

10.

DNo

L

S~Me.?

{c}

~

DYf18

Ale 'rOU reeeivq anv I*IDdic peyments lperlsians, annuitie8.
mlrMNlnt ~ etc.1 from the: fecJer$l GlMlmment. ar from IInI
$uno or lacal g~? (This 1ncUie& caah Social SItCUJity benldrm
ami rllilroad retirement enllUftiH as wei as othllll' 1adete1. :state or local

govenment payments such a. dvil service, tuch"'s poIioIemeo'•• ancl
firemen'. IIInnuit~ pensions. or retinmenl peymlntS. It daet not
I"duda wOtkvf's compensaticn payments or vetenns AclmlnistratiOIl
life irlSurancl!l P*vments.)
(II "Yes• .. answer ,b}. ft;/, Md (d}.)
(II "'No, ~ go 011 to IttIm ."J

DYes

DNCI

Dyes

D~

.

•

Ib)

{dj

Shew the amcxm of yaw ~ (befan any

deduc:tion for IUe insurance. heellh inlUnlnce.. .c.t

II;) Is you PIIymem .,..dll monthly?
'N "'7tto... bow tJI!ten? Twke-monrllly. weekly,

Dves

•

,D

.a

Oft to

IeIm 1U

DVelJ

DNo

etI:.) gavlf'fWneRt payment? (t)t, n« indude womw',s
t:mnp~. I8BidutII ~t frwn the RIIIIIHd Ra~ BoITd ttl
V_ _ A~,.rfGn iIffJ ~ PfJY1JlflRIS.J

Dyes

DNo

gov«nment flaytft8nt ell defNd In quasthn
10W (do not Include the e.oecieI age 72 payment) whether Of rlIn you ...
actually ltIWiving one? (You are eliglllll if ycu could r.cellte a gowmmenl
payment by --vinlll far it. I' yao ere new worldng. vau aN) li~"'ise
eliQibllt If VOU could receive a gawmll'll18nt paymllnl. upon appIlca1ion Or
O1herwiH, by rftirinaJ

Dyes

DNo

I. your payment from th~ vearans AdrninitMrtion based upon
M~onnKtlid di$abl1i'ty Of a seMC8-CCnnec:ted d.1tI?

•

fl. Have you received

ill t~1IIUfI

'W•• r.;tv,

lillYIT*'! In pI.ce I)f a

period~

(month",.

•

12.

No

Show the name of the agency or organilation fn:Hn whicll1he pgyment Is received:

Ilf 1he 0f9IIII1zetIon kI (dl iuhe V...... Admiftititratil;lll. an..., lIMn eel. H not.

fa!

o

etc.'

Are you eligible for ill periudie

•

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13.

(.II)

,.

Check tJn$ of the follOwing;

o

Are you ncrw:

o

MARRIED

irf you 1ft noW "'MAMIE/)'" or "\oWlJowm­
(01

ENTat YOUR W!FI'S MAIDEN NAME
OR YOUR HUSBAf>.I)'S NAME
(Hrrtiefttlr,."",." tfllIII

~.J

,

o SINGLE

WlOOVllB)

SPOUSE'S DATE
ClF~RTH (II

1MIbIIM'D (J1tIe_

YOUR SPOUSE'S

DATECF
MMFlrAQ

SOCIAL SECURITY NUMBI!R
(II,... fir 1mfnD8m.. .. indicatII.fi

-~-

(0)

14­

DDlvo~ED

~ ibJ tJtWJ {r;:J.1

If VOW SpOUSl is cf8C8Dllld• .,.... the ddt 0' death

---­

-­

II

(8' Is ytU' . . . . . NCliMng any ,*iodi~ p!MMlJtS Ipensklnl. annl.ities......... Pavn'llnta, Mil.) ftOM the Fedllral

UO'f8rrmt111t 01' fram IInf StId6 or toc.I g(Mllft'ln'llnt? lTIli:1 iIK;Iude$ t:II:Ih Sat:181 StJt:.utftr IJitntrtIIs lind tfIikoiltl
retiremf1nt 4IfNNlifiu •• r.wII U othM fetJMlJ, &taN lit" J«:(I/ (JIJ1IfI/tftIrIIIII IIItI)9m!III:I SIUdI _ dWl~. MMhIllf),
~ .. fIIJd fiIwrfINI'$ fInIIUifie!fI, pt1t&1IIlGm, tIT I'tlt1IrtmIInt P"'JfNDrtI. It dHfI fKIIt irN:Iudf: wmlI:4tr'$
~_ ~'JmIII!I¥l¥ or

VefWBIV AdministliJliIJIt /h1nt!iunlmJfl~.

DV8$

til -Yet." MS1NiIf lb;, loJ, fJ1'Id IdJJ
I" "MI... P on "fJ'J lam 15.}

IN Shl)w the oIIml'lUllt ut your

M,

~

/Dr JiJt

" , 8 paymInt

~e, hefIftI;

iblllorrJ fel

iMrIntnce.

No
r

I !fCIU' ",0.&'" paymen1 mlldlt monthlv} {If -.Nd, ..
how d'IttItJ'I T~hIy. W'eI!Ik", tm:.J

eIt:.}

I

D

DV8$

,0

NI:.

~

IeII Show tho DIme of ttIe agency 01' oroarilation ftom whN:::h 1he pavrnenl is rec81ved:

(If the ~foIIln fd} hI th, V~. Admi"nisrnttJon. MftmT IttIm

fill .s your

~Llaa's

Ie}. If ndt, IJ() IJS1IO item 1 '1.1

P*'!fM1II't ~m tho Vottnn,. hmlrilitraticl't baaed
IijI lIIlIiIIVjce.eonnOC'ted deI1h7....

DV"i-

ONO

p.IbIic aulstllnC18 pll)lrT'l8tlts Of MId.r•
Sl4Jpi8l'Mnll1 Sacurity 1I1ICQme P8'II"Dents which taka lnto lIICCount YOllr
Meds frI~ng elgtilty hlr, or tho iIU11O&nt of, such payment?--+

DV"

DNo

~ ~ II lump-sum P41Y'MM In place .of a petiodi(l
~Hy, 1Itt:.) gO'lMllMMent payment? (Do Mt ~ Wtld'M's
~1NHt. raidutd
Itr:Jm the /WIfQfId Refifemerlt /k;Ml 01'
V.,tMtM A..,.i1Itkwt life iRIIfmIncf: ptIyIIttIIfts..)

o

VIIS

Ol'kl

Dv.

ONe»

upx'IlII C81'¥ic:.connecbld diA3bility or

16. Is your IiPOUM

16. Has yotI"
Imonthly,

..

RlCXllVlng

pIIvmant

•

17. Is your

~ "igible for It pefiodic govtIII'1Ut18I' PavmMt .. defi'llJd .n
question 14(.' (fncUdjRa the lPICIiallilglJ 72 p~entJ. 'II'IIhedwIr (Jf not your
apaiUH is actuallv receMng ana? (Your ~. is aligiblll Jf your SPOUSllll
(lCluld QIIXIM a liIovel"r1m8nt PayII'IIII'It by UYing for it. If your tpOuse II
I'I.OW working. your 8pCIILIIe is 1...._ tIIlglble If Yi!I.It tPOUIG GOUld receiYe •
gov..........nt ~1IIIlt• .,.pon appJies1ion CIf DtharwiH, by retting.) _

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18. H.... YGfJr IPIlUSIICftI' .n;aged In W'Gi'k that was cau.... UI"Idet the SodeI
SeC\lritv .,....... gf II CQWdry other thin the Ur;iNd State&7
II

DNt.I

DYes

.

If ·Ye,,· Jillt 1M CfIMIotI'V(iIs):

.

,

1

etROf.LMENT IN THE MEDICARE SUPPlEM94TAR'f MIiDlCAL INSURANCE PLAN: The mMli~ in-'ler1C41 benefits
p., payiJ for most of the CO$U ", j)hy.iCiantI' 8Ild s~rgegn.· servil::es. and nlabld rnedEelil sentir:al wbich ,ro not
oavered by the hospitallnsuran.::. pllItI. CCWeraolll and_ 1h1a SUPPlEMENTARY MEDICAl. INSURANCE PLAN does not
'Pply to Ifl.Wt mtdA explP:tD1I incurred 0lI'IiI1de the Unit6d StahI$. Your Social Security district office will M glad to
ellcplillin tn. detail.. of the plan and gMt yoo a leaflet which . .ail\$' wf'Ie.t .MOIIII lllre oovered . . how payment is
madill undlit tle pfclQ.

.

Once you a,.. e:nrollad in tn, "kI." "Il1U will haq 10 pay • monthlv premiurn to CClvl!II" part (If the (lIQISt of YQU" medic:a~
VwClrlnoe pnnectkIn. 'the Fedaral Gcwernrntnt oontriblltlll an equal .-nOUftt or I'I\IIlI'II toward ... (JOlt of your
in'!,Irenee. fJvmiums will be dldl.actld from It'LY mQn1i'IIy S'oci" Seariy, ,.ufroad rnl'llTll!lnt" or dvlI tilWVialll benefit
cl'Ia.ab ~ ~. If you dD not NIC8ive aJCh ben...... ~ will !)e no-tifild about wnen. where, and how to 'PIIIY \lOur
pramiuMI>. If you d~ IJOt enroll. this ume, you may have to PIlV i'III high. pn:miurn iJl1d your 4XM11'188 will be deIay8d.

19. 00 vcu wish ta enroll" the MEDICAl. SUPPLEMIiNTARY MEDICAL INSURANCE PlAN?

o VIlIS

DNo

The 1'IV'ent. listed below may aHect monthly ~" ..... \be 3plGi1ll 8g1t-7Z-or-awr pNNiskm.·Yau will find 80
lIlCIlIanetion gf ~ 1I-v afflICt pevmt!IIMS in 1h8 ·Flgbts and Re$1o'~mitlUme.h booldet which you 'lM1 receiWl. tf any
one of die.. 9¥'8nt81 OCICW'S, you mult notIfy Ih_ Socill Seeurlty Admiri,trl.'tiQll ",omp-ltV.

lal Vw D~ your!IIIXIU:tD bec:orne EUGIBlE FOR PERIODIC GOVSRNMENTAL PAYMENTS OR THE AMOUNT Or::
PllESENT PAYMEIIfT CHANGES CpenskJl'ls.. annuit_ Iilltir$t1lSl1t PlJYOIents, etc.l. wtle1h1ll' tram me Federal
;lovemment til' fn2tn tha Stitto or local tClverment.

Cb)

Vcu or yoor 'fICIU" IlIOlIIivlt PUBLIC ASSISTANCE OIsh payrneclt* fJl
P8f;m8nts.

F«Ieral S'UPfLIiMENTAL SECUFlITV INCOME

.

lei "'fJur MAl-mY or . . DIVORCED.
ttJl

'igU reside outside the

50 S'!at8S of the U.S. 1111111 . . ~lJtJiGt of Columbia.

I agrM to nortfy the $O

Bid;., BaltlmOfe. UD 21235·0001. Send onlf c"""""* relalidg 10 our .....me it . . . . . . . . .e19 .... aIfIc.

rlBtad above. AU RlqUUQ for SociIISaGIIIity . . . and OCh8r ~1CMI ird'Gnutiaa JhouIcl be HIlt to your

I..,.. SocIal'Secuity oHJce. Wboaa ...._Is I. . . und. S4XIiIII s.mty Administr.a1ion In Ihe U.s.

Gcwemmem liil8Glion of yow telephane

ell....,.,.

See Revised Paperwork
Reduction Act

....
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The following revised Privacy Act Statement will be inserted into the form as its
next scheduled reprinting.

Privacy Act Statement
Collection and Use of Personal Information
Sections 228(a), 205(a), and 1872 of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to determine if you
and your spouse are entitled to insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent an accurate or timely decision on your claim, and
could result in the loss of some benefits or insurance coverage.
We rarely use the information you supply for any purpose other than for determining
eligibility. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following 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. § 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 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 only comments relating to our time estimate to this
address, not the completed form.