Current SSA-2512

SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OMB NO. 0960-0120

TOE 420

PRE-1957 MILITARY SERVICE -- FEDERAL BENEFIT QUESTIONNAIRE
Privacy Act Statement - Section 217, of the Social Security Act, as amended, authorizes us to collect this information. The information is needed to permit the
Social Security Administration (SSA) to establish whether the wage earner's military service may be used to determine entitlement to or the amount of Social
Security benefits. The information you furnish on this form is voluntary. However, failure to provide all or part of the information requested on this form could result
in the loss of some benefits or insurance coverage.
We rarely use the information you supply for any purpose other than making a determination upon your claim. 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: (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
Veteran Affairs); (3) to make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; (4) to State
agencies to assist in the determination process for initial and continuing eligibility in their income maintenance programs; (5) to the Department of Education for
determining the eligibility of applicants for Basic Educational Opportunity Grants; and (6) 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 and
administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record Notices 60-0089 and 60-0103. The notices, additional information regarding
this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.
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 only comments relating to our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
NAME OF WAGE EARNER (FIRST NAME, MIDDLE INITIAL, LAST NAME)

SOCIAL SECURITY NUMBER

NAME USED IN SERVICE (IF DIFFERENT FROM ABOVE)

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 16, 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 90
consecutive days or more while on active duty or active duty for training.
(B) DATE ACTIVE DUTY
BEGAN

(A) BRANCH OF SERVICE

MONTH

2.

DAY

YEAR

(C) DATE SEPARATED
FROM ACTIVE DUTY
MONTH

DAY

(D) RATE OR
RANK

YEAR

RESERVE SERVICE (OTHER THAN ACTIVE RESERVE DUTY SHOWN ABOVE.)
(B) DATE MEMBERSHIP
BEGAN

(A) BRANCH OF SERVICE

MONTH

DAY

YEAR

(C) DATE MEMBERSHIP
ENDED
MONTH

DAY

(D) RATE OR
RANK

YEAR

PART II. MILITARY RETIREMENT INFORMATION
3.

(a)

Not retired (If checked, go on to Part III)

(b)

Retired

{

(If veteran is giving information complete (c) and (d) below.)
(If survivor of veteran is giving information go on to Part III)

(c) Basis for retirement (Complete even if not receiving pay)
Length of service

Disability

Reserve service -- Payable at age 60
Other

Basis unknown

(PLEASE SPECIFY)

(d) Did you waive all or part of your retirement pay as a condition to receive veterans' administration
disability compensation or to receive "civil service" (Office of Personnel Management) or other
Federal agency credit for your military service?
Yes
No
Form SSA-2512 (06-2010) EF (06-2010)

(Over)

PART III. CIVILIAN FEDERAL AGENCY BENEFIT INFORMATION
(Including Veterans Administration)
4.

(a) Have you ever been, or do you expect to be, entitled to receive a civilian Federal benefit?
Yes
No (If "no", omit the remaining questions and sign below.)
(b) Please check type of benefit that you are receiving, were receiving, or that you expect to
receive.
Age or length of service
Disability
Survivor

5.

Other

(PLEASE SPECIFY TYPE)

(a) Name of Federal agency that was, is now, or will be paying benefit:
Office of Personnel Management (Formerly Civil Service Commission)
Veterans' Administration (Check only if receiving benefits because of waiving all or part of
military retirement pay)
Office of Workers Compensation Programs (Check only if receiving benefits because of
waiving all or part of another Federal benefit)
Specify in remarks the agency and the type of benefit waived.
Other (Specify)
(b) Years of civilian Federal
employment

6.

(c) Date claim filed

(d) Federal Benefit claim number

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

(c) Date last worked
REMARKS: (You may use this space for any explanations. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on this form and it is true and correct to the
best of my knowledge. I understand that anyone who makes or causes to be made a false or misleading statement
about material fact in an application for the use of determining a right to payment under the Social Security Act
commits a crime punishable under Federal law by fine, imprisonment, or both.

SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

SIGN
HERE

Telephone Number (include area code)

u

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

ZIP Code

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State and ZIP Code)

Address (Number and street, City, State and ZIP Code)

Form SSA-2512 (06-2010) EF (06-2010)