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**Social Security Administration**

**USDVA, U.S. Embassy**

**1131 Roxas Blvd. 0930 Manila Philippines**

SSN: **Fax: (632) 5221514** PROTFL/REP:

================================================================================

**CLAIMS QUESTIONNAIRE**

**For Claims from Australia/New Zealand**

The claimant's answer to this Questionnaire will determine (1) if the
claimant meets the minimum entitlement factors and (2) what Forms and
Documents will be required to complete the claim process. If unsure of
actual numerical figure, please answer the estimate. Use a separate
paper for more answer space.

+-----------------------------------------------------------------------+
| **CLAIM TYPE**                                                        |
|                                                                       |
| Check below the type of Benefit the Claimant is applying for?         |
|                                                                       |
| \[\]Retirement, \[\]Disability, \[\]Spouse, \[\]Child,                |
|                                                                       |
| \[\]Widow, \[\]Parent, \[\]Burial, \[\]Divorced Spouse,               |
| \[\]Mother/Father of a Minor Child, \[\]Medicare, \[\]Other:          |
+-----------------------------------------------------------------------+
| **US WORKER PRIMARY ACCOUNT INFORMATION**                             |
|                                                                       |
| US Worker Name: **     **                                             |
|                                                                       |
| US Worker US Social Security Number: **     **                        |
|                                                                       |
| US Worker Date of Birth: **     **                                    |
|                                                                       |
| US Worker Date of Death if deceased: **     **                        |
|                                                                       |
| US Worker Citizenship(s): **     **                                   |
|                                                                       |
| US Worker Residence Address: **     **                                |
|                                                                       |
| Did US Worker have US military Service? \[Yes or No \]                |
|                                                                       |
| What are the Non-USA countries/nations that US Worker worked in the   |
| past? List the [COUNTRY]{.underline} and Estimate of [ACCUMULATED     |
| MONTHS OF WORK PERIOD]{.underline}.                                   |
|                                                                       |
| 1\. **           **                                                   |
|                                                                       |
| 2\. **           **                                                   |
+-----------------------------------------------------------------------+
| **CLAIMANT INFORMATION**                                              |
|                                                                       |
| Claimant Name: **     **                                              |
|                                                                       |
| Claimant own US Social Security Number: **     **                     |
|                                                                       |
| Claimant Date of Birth: **     **                                     |
|                                                                       |
| Claimant Citizenship(s): **     **                                    |
|                                                                       |
| Claimant Residence Address: **     **                                 |
|                                                                       |
| Claimant Marriage Information:                                        |
|                                                                       |
| [Spouse]{.underline} [Spouse]{.underline} [Marriage                   |
| Start]{.underline} [Marriage End]{.underline} [Marriage If Ended\     |
| ]{.underline} [Name]{.underline} [Birthday]{.underline} [Date &       |
| Place]{.underline} [Date & Place]{.underline} [Divorce or             |
| Death]{.underline}                                                    |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_                                            |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_\_\_                                            |
|                                                                       |
| If Claimant have/had a US Permanent Resident Alien Card (Green Card), |
| have                                                                  |
|                                                                       |
| Claimant resided in USA for at least 5 years? \[Yes or No \]          |
|                                                                       |
| Had Claimant been deported from the USA? \[Yes or No \]               |
|                                                                       |
| Is Claimant currently WORKING or SERVICE-AVAILABLE-FOR-A-FEE MORE     |
| THAN 45.HRS A MONTH? \[Yes or No \]                                   |
|                                                                       |
| Claimant is entitled to WHAT OTHER TYPE OF US PENSION? **     **      |
|                                                                       |
| Claimant is entitled to WHAT OTHER TYPE OF NON-US PENSION BASED ON    |
| WORK (such as Superannuation, Company Disability Compensation,        |
| Company Retirement Pension, etc.)? **     **                          |
+-----------------------------------------------------------------------+
| **POSSIBLE DISABILITY CLAIM**                                         |
|                                                                       |
| > INFORMATION: US Social Security define DISABILITY as a condition    |
| > wherein the person is no longer capable of performing a             |
| > substantially gainful activity (income-generating work) because of  |
| > a permanent, long-term, or terminal illness that is proven by       |
| > medical record.                                                     |
|                                                                       |
| 1\. Is Claimant Medically certified to be Disabled? \[Yes or No \]    |
|                                                                       |
| 2\. If Claimant is disabled: please describe below the Medical Term   |
| and Nature of your disabling illness or physical defect. **     **    |
|                                                                       |
| 3\. Understanding the SSA definition of Disability above, what is the |
| Date your Disability Started?\[Month/Day/Year\]: **     **            |
+-----------------------------------------------------------------------+
| **CHILDREN.** Enumerate below all CHILDREN of US worker (Type of      |
| Child includes: natural child, step child, adopted child)             |
|                                                                       |
| [Date & Place]{.underline} [Disabled?]{.underline}                    |
| [WorkingChild?]{.underline} [Married?]{.underline}                    |
|                                                                       |
| [Name at Birth]{.underline} [of Birth]{.underline} [\[Yes or          |
| no\]]{.underline} [\[Yes or No\]]{.underline} [\[Yes or               |
| No\]]{.underline}                                                     |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_                         |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_                         |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_                         |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_               |
| \_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_                         |
|                                                                       |
| Use separate page if necessary.                                       |
+-----------------------------------------------------------------------+
| **MARRIAGE/DIVORCE RECORD.** Enumerate below. If US Worker is alive   |
| and has Spouse or Divorced Spouse who is currently or approaching age |
| 62. OR US Worker is deceased and has Widow or Divorced Spouse who is  |
| currently or approaching age 60.                                      |
|                                                                       |
| [Date & Place]{.underline} [Age]{.underline} [Deceased?]{.underline}  |
| [Current]{.underline}                                                 |
|                                                                       |
| [Name at Birth]{.underline} [of Birth]{.underline} [Now]{.underline}  |
| [\[Yes or no\]]{.underline} [Address]{.underline}                     |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                          |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                |
|                                                                       |
| Use separate page if necessary.                                       |
+-----------------------------------------------------------------------+

**[Print and sign this form, then mail/fax it to SSA
Manila.]{.underline}**

**Claimant Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date
Signed: \_\_\_\_\_\_\_\_\_\_**