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

TP8D6GÃT@8VSDU`Ã69HDIDTUS6UDPI UP@Ã#!

APSHÃ6QQSPW@9 PH7ÃIPÃ(% !

35( 0,/,7$5< 6(59,&( )('(5$/ %(1(),7 48(67,211$,5(
QSDW68`à 68UQ6Q@SXPSFà 68Uà IPUD8@)à Uurà Tpvhyà Trpvà 6qvvhvà và huvrqà à pyyrpà urà Dshvà à uvà sà qrà rpv
! &à sà urà Tpvhyà Trpvà 6pà hà hrqrqà ià #!à VT8à # &à Uurà Dshvà và rrqrqÃÃrhiyvuÃururÃurÃhtrÃrhrÃvyvhÃrvprÃhÃir rqà à qrrvrà rvyrrà à à urà hà sà hà Tpvhyà Trpvà irrsvà hhiyrà `à rrà à uvà rrà và yhà urrà shvyrà vqrÃhyyÃÃhÃsÃuvÃvshvÃpyqÃryÃvÃurÃyÃsÃrÃirrsvÃÃvhprÃprhtrÃ6yutuÃurÃvshvÃÃuvÃsÃvÃhryÃrqÃs hà rà urà uhà hrqà hirà urrà và hà vivyvà uhà và urà hqvvhvà sà urà Tpvhyà Trpvà thà à và urà hqvvhvà sà th rvvtÃpqvhvÃvuÃurÃTpvhyÃTrpvÃ6qvvhvÃvshvÃhirÃqvpyrqÃhÃsyy)ÃUÃurÃihpuÃsÃurÃvyvhÃÃrrqÃvÃÃÃur Wrrhà 6qvvhvà à urà Arqrhyà htrpà hà rvrqà à qrrvrà vsà urà vyvhà rvprà hÃirÃrqÃsÃTpvhyÃTrpvÃrÃÃpyÃvu ArqrhyÃyhÃuvpuÃrvrÃurÃryrhrÃsÃvshvÃsÃTpvhyÃTrpvÃrpqÃhqÃÃshpvyvhrÃhvvphyÃrrhpuÃhqÃhqvÃhpvvvrÃrrqrqÃÃhr urÃvrtvÃhqÃvrrÃsÃurÃTpvhyÃTrpvÃth

UurÃQhrxÃSrqpvÃ6pÃsà (($ÃrvrÃÃÃvsÃÃuhÃuvÃvshvÃpyyrpvÃvÃvÃhppqhprÃvuÃurÃpyrhhprÃrvrrÃsÃrpv "$&ÃsÃurÃQhrxÃSrqpvÃ6pÃsà (($ÃXrÃhÃÃpqpÃÃÃhqÃÃhrÃÃrvrqÃÃrqÃÃhÃpyyrpvÃsÃvshvÃyr vÃqvyhÃhÃhyvqÃPH7ÃpyÃirÃÃXrÃrvhrÃuhÃvÃvyyÃhxrÃÃhià ÃvrÃÃpyrrÃuvÃsÃUuvÃvpyqrÃurÃvrÃvÃvyyÃhxrÃÃrhq urÃvpvÃthurÃurÃrprhÃshpÃhqÃsvyyÃÃurÃs
I6H@ÃPAÃX6B@Ã@6SI@SÃADSTUÃI6H@ÃHD99G@ÃDIDUD6GÃG6TUÃI6H@ TP8D6GÃT@8VSDU`ÃIVH7@S

I6H@ÃVT@9ÃDIÃT@SWD8@ÃDAÃ9DAA@S@IUÃASPHÃ67PW@

T@SWD8@ÃIVH7@S

3$57 , 0,/,7$5< 6(59,&( +,6725< 35,25 72 (QWHU WKH PRQWK GD\ DQG \HDU RI DQ\ DFWLYH RU UHVHUYH PLOLWDU\ VHUYLFH GXULQJ WKH SHULRG 6HSWHPEHU WKURXJK 'HFHPEHU ,I WKH VHUYLFH %(*$1 %()25( 25 (1'(' $)7(5 WKLV SHULRG VKRZ WKH VWDUWLQJ RU HQGLQJ GDWH HYHQ WKRXJK LW LV RXWVLGH WKH SHULRG $&7,9( '87< 5(*8/$5 $1' $&7,9( 5(6(59( 6(59,&( (QWHU LQIRUPDWLRQ DERXW 5(*8/$5 $&7,9( '87< RI DQ\ GXUDWLRQ DQG DERXW 5(6(59( $&7,9( 6(59,&( RI FRQVHFXWLYH GD\V RU PRUH ZKLOH RQ DFWLYH GXW\ RU DFWLYH GXW\ IRU WUDLQLQJ
6ÃÃ7S6I8CÃPAÃT@SWD8@ 7ÃÃ96U@Ã68UDW@Ã9VU` 7@B6I HPIUCÃÃÃÃÃÃÃÃÃÃ96`ÃÃÃÃÃÃÃÃÃÃ`@6S 8ÃÃ96U@ÃT@Q6S6U@9 ASPHÃ68UDW@Ã9VU` HPIUCÃÃÃÃÃÃÃÃÃÃ96`ÃÃÃÃÃÃÃÃÃÃ`@6S 9ÃÃS6U@ÃPS S6IF



5(6(59( 6(59,&( 27+(5 7+$1 $&7,9( 5(6(59( '87< 6+2:1 $%29(
6ÃÃ7S6I8CÃPAÃT@SWD8@ 7ÃÃ96U@ÃH@H7@STCDQ 7@B6I HPIUCÃÃÃÃÃÃÃÃÃÃ96`ÃÃÃÃÃÃÃÃÃÃ`@6S 8ÃÃ96U@ÃH@H7@STCDQ @I9@9 HPIUCÃÃÃÃÃÃÃÃÃÃ96`ÃÃÃÃÃÃÃÃÃÃ`@6S 9ÃÃS6U@ÃPS S6IF

3$57 ,, 0,/,7$5< 5(7,5(0(17 ,1)250$7,21 D E 1RW UHWLUHG ,I FKHFNHG JR RQ WR 3DUW ,,, 5HWLUHG

^

,I YHWHUDQ LV JLYLQJ LQIRUPDWLRQ FRPSOHWH F DQG G EHORZ ,I VXUYLYRU RI YHWHUDQ LV JLYLQJ LQIRUPDWLRQ JR RQ WR 3DUW ,,, 'LVDELOLW\ %DVLV XQNQRZQ

F %DVLV IRU UHWLUHPHQW &RPSOHWH HYHQ LI QRW UHFHLYLQJ SD\ /HQJWK RI VHUYLFH 5HVHUYH VHUYLFH 3D\DEOH DW DJH 2WKHU
QG@6T@ÃTQ@8DA`

G 'LG \RX ZDLYH DOO RU SDUW RI \RXU UHWLUHPHQW SD\ DV D FRQGLWLRQ WR UHFHLYH YHWHUDQV
DGPLQLVWUDWLRQ GLVDELOLW\ FRPSHQVDWLRQ RU WR UHFHLYH FLYLO VHUYLFH 2IILFH RI 3HUVRQQHO 0DQDJHPHQW RU RWKHU )HGHUDO DJHQF\ FUHGLW IRU \RXU PLOLWDU\ VHUYLFH" )RUP 66$ ()

2YHU

3$57 ,,, &,9,/,$1 )('(5$/ $*(1&< %(1(),7 ,1)250$7,21 ,QFOXGLQJ 9HWHUDQV $GPLQLVWUDWLRQ D +DYH \RX HYHU EHHQ RU GR \RX H[SHFW WR EH HQWLWOHG WR UHFHLYH D FLYLOLDQ )HGHUDO EHQHILW" QG@6T@ÃTQ@8DA`ÃU`Q@

D 1DPH RI )HGHUDO DJHQF\ WKDW ZDV LV QRZ RU ZLOO EH SD\LQJ EHQHILW 2IILFH RI 3HUVRQQHO 0DQDJHPHQW )RUPHUO\ &LYLO 6HUYLFH &RPPLVVLRQ 9HWHUDQV
$GPLQLVWUDWLRQ &KHFN RQO\ LI UHFHLYLQJ EHQHILWV EHFDXVH RI ZDLYLQJ DOO RU SDUW RI PLOLWDU\ UHWLUHPHQW SD\ 2IILFH RI :RUNHUV &RPSHQVDWLRQ 3URJUDPV &KHFN RQO\ LI UHFHLYLQJ EHQHILWV EHFDXVH RI ZDLYLQJ DOO RU SDUW RI DQRWKHU )HGHUDO EHQHILW 6SHFLI\ LQ UHPDUNV WKH DJHQF\ DQG WKH W\SH RI EHQHILW ZDLYHG 2WKHU 6SHFLI\ E


0267 5(&(17 )HGHUDO HPSOR\HU D 1DPH RI DJHQF\ LI GLIIHUHQW IURP D DERYH E &LW\ DQG 6WDWH ZKHUH HPSOR\HG

F 'DWH ODVW ZRUNHG
5(0$5.6
, NQRZ WKDW DQ\RQH ZKR PDNHV RU FDXVHV WR EH PDGH D IDOVH VWDWHPHQW RU UHSUHVHQWDWLRQ RI PDWHULDO IDFW LQ DQ DSSOLFDWLRQ RU IRU XVH LQ GHWHUPLQLQJ D ULJKW WR SD\PHQW XQGHU WKH 6RFLDO 6HFXULW\ $FW FRPPLWV D FULPH SXQLVKDEOH XQGHU )HGHUDO ODZ E\ ILQH LPSULVRQPHQW RU ERWK , DIILUP WKDW DOO LQIRUPDWLRQ , KDYH JLYHQ LQ WKLV GRFXPHQW LV WUXH

6,*1$785( 2) $33/,&$17
6LJQDWXUH )LUVW QDPH PLGGOH LQLWLDO ODVW QDPH :ULWH LQ LQN 'DWH 0RQWK GD\ \HDU 7HOHSKRQH 1XPEHU LQFOXGH DUHD FRGH

6,*1 +(5( 0DLOLQJ $GGUHVV 1XPEHU DQG VWUHHW $SW 1R 32 %R[ RU 5XUDO 5RXWH
&LW\ DQG 6WDWH

=,3 &RGH

:LWQHVVHV DUH UHTXLUHG 21/< LI WKLV DSSOLFDWLRQ KDV EHHQ VLJQHG E\ PDUN ; DERYH ,I VLJQHG E\ PDUN ; WZR ZLWQHVVHV WR WKH VLJQLQJ ZKR NQRZ WKH DSSOLFDQW PXVW VLJQ EHORZ JLYLQJ WKHLU IXOO DGGUHVVHV 6LJQDWXUH RI :LWQHVV $GGUHVVÃIirÃhqÃrrÃ8vÃThrÃhqÃaDQÃ8qr 6LJQDWXUH RI :LWQHVV $GGUHVV
IirÃhqÃrrÃ8vÃThrÃhqÃaDQÃ8qr

)RUP 66$ ()