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

SOCIAL SECURITY ADMINISTRATION

FORM APPROVED
OMB NO. 0960-0120

TOE 420

PRE-1957 MILITARY SERVICE - FEDERAL BENEFIT QUESTIONNAIRE
NAME OF WAGE EARNER (FIRST NAME, MIDDLE INITIAL, LAST NAME)

SOCIAL SECURITY NUMBER

NAME USED IN SERVICE (IF DIFFERENT FROM ABOVE)

SERVICE NUMBER

PART 1. 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.
(A) BRANCH OF SERVICE

2.

(B) DATE ACTIVE
(C) DATE SEPARATED
DUTY BEGAN
FROM ACTIVE DUTY
MONTH
DAY
YEAR MONTH
DAY
YEAR

(D) RATE OR RANK

RESERVE SERVICE (OTHER THAN ACTIVE RESERVE DUTY SHOWN ABOVE.)
(A) BRANCH OF SERVICE

(B) DATE ACTIVE
(C) DATE SEPARATED
DUTY BEGAN
FROM ACTIVE DUTY
DAY
YEAR
MONTH
DAY
YEAR MONTH

(D) RATE OR RANK

PART 2. MILITARY RETIREMENT INFORMATION
3.

(a)

Not retired (If checked, go on to Part 3)

(b)

Retired

{

(If veteran is giving information complete (c) and (d) below.)
(If survivor of veteran is giving information go on to Part 3)

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

Disability

Reserve service -- Payable at age 60

Basis unknown

Other
(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
PART 3. 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

Other

Form SSA-2512 (06-2014) EF (06-2014)

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(Please Specify Type)

5.

(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)
Telephone Number (include area code)

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)

Form SSA-2512 (06-2014) EF (06-2014)

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

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Privacy Act Statement
PRE-1957 Military Service - Federal Benefit Questionnaire
Section 217 of the Social Security Act, as amended, authorizes us to collect this information. We will use the information
you provide to establish whether the wage earner’s military service may be used to determine entitlement to or the
amount of Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent
us from making an accurate decision on your claim and could result in the loss of benefits.
We rarely use the information you supply for any purpose other than the reason stated above. 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 and
improvement of Social Security programs (e.g., to the Bureau of the Census).
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.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled, the Claims
Folders System (60-0089) and the Supplemental Security Income Record and Special Veterans Benefits System
(60-0103). These notices, additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at any 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.

Form SSA-2512 (06-2014) EF (06-2014)

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