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Form Name	Ssa 2490 Bk Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	ssa 2490 bk form, ssa form 2490, form ssa 2490, ssa 2490 bk

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Form SSA-2490-BK (05-2017) UF
Discontinue Previous Editions	Page 1 of 7
Social Security Administration	OMB No. 0960-0448

	(Do not write in this space)
APPLICATION FOR BENEFITS UNDER A
U.S. INTERNATIONAL SOCIAL SECURITY AGREEMENT

If the worker is living, this application should be completed by or on behalf of the worker. If the worker is deceased, this application should be completed by one of the worker's survivors who is claiming benefits under the provisions of the international social security agreement.

PART 1

Complete Part 1 in all cases.

1. (a) Print name of worker (First name, middle initial, last name)	(b) U.S. Social Security Number

2.Provide the following information about the worker's social security credits (coverage) and last place of residence in the foreign country.

(a)Use columns (1) - (5) to enter information about the worker's periods of employment or self-employment in the foreign country. (If additional space is required, enter the information in Remarks -- item 19.)

(1) Dates Worked	(2) Name and Address of	(3) Type of Industry	(4) Social Insurance	(5) Name of Agency to
(From - To)	employer or self-employment	or business	Number used	which contributions paid
	activity		while working

(b)Use columns (1) - (4) to enter information about the worker's periods of coverage under the foreign social insurance system which are not based on employment or self-employment (e.g., coverage for voluntary contributions, deemed or equivalent coverage, periods of military service, illness, etc.)

(1) Dates Covered	(2) Type of coverage	(3) Social Insurance	(4) Name of Agency to which
(From - To)		Number used for this	contributions paid (if any)
		coverage if different than
		shown in item 2(a)(4)

(City and State or Province)

PLEASE REMOVE PAGE 1 OF THIS FORM BEFORE COMPLETING THE REST OF THE APPLICATION. AFTER APPLICATION IS COMPLETED AND SIGNED, STAPLE DETACHED PAGE TO APPLICATION.

Form SSA-2490-BK (05-2017) UF	Page 2 of 7

	(Do not write in this space)
APPLICATION FOR BENEFITS UNDER A
U.S. INTERNATIONAL SOCIAL SECURITY AGREEMENT

PART 1

Complete Part 1 in all cases.

1. (a) Print name of worker (First name, middle initial, last name)	(b) U.S. Social Security Number

2.Provide the following information about the worker's social security credits (coverage) and last place of residence in the foreign country.

(1) Dates Worked	(2) Name and Address of	(3) Type of Industry	(4) Social Insurance	(5) Name of Agency to
(From - To)	employer or self-employment	or business	Number used	which contributions paid
	activity		while working

(1) Dates Covered	(2) Type of coverage	(3) Social Insurance	(4) Name of Agency to which
(From - To)		Number used for this	contributions paid (if any)
		coverage if different than
		shown in item 2(a)(4)

(City and State or Province)

Form SSA-2490-BK (05-2017) UF	Page 3 of 7

3. I apply for all benefits for which I am eligible under the provisions of the social	Name of country
security agreement between the United States and

4.This application may be used to claim benefits from the U.S. and/or the foreign country shown in item 3. Check (X) the block(s) indicating the type of benefit(s) for which you are applying under the country(ies) from which you are claiming the benefit(s).

BENEFIT CLAIMED FROM FOREIGN COUNTRY Type of Benefit Claimed From Foreign Country:

Retirement/Old-Age	Survivors	None
Disability or Sickness/Invalidity	Other (Specify)


BENEFIT CLAIMED FROM THE UNITED STATES

(a) Are you presently receiving benefits from the United States?		Yes	No
		(If "Yes" answer	(If "No" answer
		(b) below.)	(c) below.)

(b) If you are already receiving U.S. benefits, do you wish to file for a different		Yes	No
type of U.S. benefit?		Yes	No
type of U.S. benefit?
		(If "Yes" answer	(If "No" go on
		(d) below.)	to item 5.)

(c) If you are not presently receiving U.S. benefits, do you wish to file		Yes	No
for U.S. benefits at this time?		(If "Yes" answer	(If "No" go on
		(If "Yes" answer	(If "No" go on
		(d) below.)	to item 5.)

(d) Indicate the type of benefit you wish to claim from the United States:

Retirement		Disability		Survivors

INFORMATION ABOUT THE WORKER

5. (a) Print worker's name at birth, if different from item 1(a)

(b) Check (X) one for the worker		(c) Enter worker's social insurance number in the foreign country if different than
Male	Female	shown in items 2(a)(4) or 2(b)(3)

(d)If the worker's Social Security number in either the United States or the foreign country is not known, enter the worker's parents' names:

Mother's name (First name, middle initial, last name, maiden name)

	Father's name (First name, middle initial, last name)

	(e) Enter the worker's citizenship (Enter name of country)

6. Do you want this application to protect an eligible spouse's and/or child's right				Yes		No

	to Social Security benefits?



7. (a) Was the worker or any other person claiming benefits on this application a				Yes		No

	refugee or stateless person at any time?

		(If "Yes" answer			(If "No" go on
		(If "Yes" answer			(If "No" go on
		(b) below.)			to item 8.)

	(b) If "Yes" enter the following information about the person:

	Name		Dates of refugee or stateless status

Form SSA-2490-BK (05-2017) UF	Page 4 of 7

PART 2

Complete Part II ONLY if you are claiming benefits from a foreign country.

8.If you are applying for sickness or disability/invalidity benefits, enter the date you became disabled. Date (MM/DD/YYYY) Otherwise enter ''N/A.''

9. (a) If you are applying for retirement/old-age benefits, have you stopped or			Yes			No

	do you plan to stop working?

		(If "Yes" answer			(If "No" go on
		(If "Yes" answer			(If "No" go on
		(b) below.)			to item 10.)

				Date (MM/DD/YYYY)
	(b) If ''Yes,'' enter the date you stopped or plan to stop working.

10. (a) Are you applying for foreign social security benefits under a special			Yes			No

	system that covers a specific occupation (e.g., miners, seamen, farmers)?

		(If "Yes" answer			(If "No" go on
		(If "Yes" answer			(If "No" go on
		(b) and (c) below.)			to item 11.)

	(b) What was your occupation in the foreign country?

	(c) Did you perform the same type of work in the U.S?		Yes			No
	(c) Did you perform the same type of work in the U.S?

INFORMATION ABOUT THE APPLICANT

Complete item 11 ONLY if you are not the worker. If you are the worker, leave this question blank and go on to item 12.

11.	(a) Print your name (First name, middle initial, last name, maiden name)							(b) What is your relationship to the
								worker?

	(c) Enter your U.S. Social Security number				(d) Enter your social insurance number in the foreign country
					(if none or unknown, so indicate)

ADDITIONAL INFORMATION ABOUT THE WORKER

12. (a) Enter worker's date of birth (MM/DD/YYYY)				(b) Enter worker's place of birth (City, state, province, country)

13. If the worker is deceased, enter the date			(a) Date (MM/DD/YYYY)			(b) Place (City, state, province, country)
	and place of death

14. (a) Was the worker in the active military or naval service of the U.S.								Yes		No
	(including U.S. reserve or U.S. National Guard active duty for training) or							Yes		No

	a foreign country after September 7, 1939?							(If "Yes" answer		(If "No"go on to
								(b) thru (c) below.)		item 15.)

	(b) Enter the name of country served	Country						Dates of Service
	and dates of service:
	and dates of service:						FROM: (MM/DD/YYYY)		TO: (MM/DD/YYYY)

	(c) Has anyone (living or deceased) received, or does anyone expect to							Yes		No
	receive, a benefit from any U.S. Federal agency based on the worker's							Yes		No

	military or naval service?							(If "Yes" answer		(If "No" go on
								(If "Yes" answer		(If "No" go on
								(d) below		to item 15

(d)If ''Yes'' enter the following information for each person: (If additional space is required, enter the information in Remarks -- item 19)

Name	U. S. Agency	Claim No.

Form SSA-2490-BK (05-2017) UF				Page 5 of 7

15. (a) During the past 24 months, did the worker engage in employment or			Yes	No
	self-employment covered by the U.S. Social Security system?		Yes	No
	self-employment covered by the U.S. Social Security system?
		(If "Yes" answer		(If "No" go on
		(b) and (c) below.)		to item 16.)

	List the periods of work covered by the U.S. Social Security system and the name and address of the employer or self-
	employment activity

	(b) Name and address of employer or self-employment activity	Work Began		Work Ended
		(Month-Year)		(Month-Year)

	(c) May we ask any employer listed above for wage information needed to				Yes	No
	process this claim?				Yes	No
	process this claim?
INFORMATION ABOUT DEPENDENTS FOR WHOM BENEFITS ARE CLAIMED

16.			Under age 18		Yes	No
			Under age 18		Yes	No
	(a) Are there any children of the worker who are now, or were in the			OR
				OR
	past 12 months, unmarried and:		Age 18 or over and a		Yes	No
			student or disabled		Yes	No
			student or disabled

	If either block is checked "Yes", enter the information for each child. NOTE: Children include natural children, step-children
	and adopted children plus grandchildren living in the same household as the worker.

	(b) Name of child	(c) Relationship to worker			(d) Sex	(e) Date of birth
	(b) Name of child	(c) Relationship to worker			(M or F)	(MM/DD/YYYY)
					(M or F)	(MM/DD/YYYY)

17.The spouse, widow or widower of the worker may be eligible for a benefit. In addition, a former spouse of the worker may be eligible as a divorced spouse, widow or widower. Provide the following information about any spouse or former spouse of the

worker.	SPOUSE	FORMER SPOUSE	FORMER SPOUSE

(a)Name (including maiden name)

(b)Date of Birth (MM/DD/YYYY)

(c)Date of Marriage (MM/DD/YYYY)

(d)Date of Divorce (if any) (MM/DD/YYYY)

(e)Country of Citizenship

(f)Social Insurance Number in foreign country

(g)U. S. Social Security Number (if any)

Form SSA-2490-BK (05-2017) UF		Page 6 of 7

18. (a) Has the worker, or any other person listed on this application, ever previously	Yes	No
applied for U.S. Social Security benefits or social insurance benefits from the	(If "Yes" answer	(If "No" go on
country shown in item 3 of this application?	(If "Yes" answer	(If "No" go on
country shown in item 3 of this application?	(b) thru (f) below.)	to item 19.)
	(b) thru (f) below.)	to item 19.)

If "Yes" enter the information requested for each person. I (If additional space is required, enter the information in Remarks -- item 19.)

(b) Name

(d) Claim Number

(e)Amount of benefit (if benefit awarded)

(f) Agency which approved or denied claim

19.

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

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 30minutes to read the instructions, gather the facts, and answer the questions. SEND

THE COMPLETED FORM ALONG WITH ANY EVIDENCE 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.

Form SSA-2490-BK (05-2017) UF	Page 7 of 7

Privacy Statement

Collection and Use of Personal Information

Sections 205(a), 205(c)(2), and 233 of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide to determine potential eligibility for receiving benefits under an international agreement on social security or to determine if we need additional information to support any claims.

Furnishing this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claims. We rarely use the information you supply us for any purpose other than for the reasons explained above. However, we may use the information for the administration of our programs including sharing information:

1.To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and Department of Veterans Affairs); and,

2.To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).

A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Record Notice entitled, Earnings Records and Self Employment Income System, (60-0059). Additional information about this and other system of records notices and our programs is available online at www.socialsecurity.gov or at your local Social Security office.

We may share the information you provide to other health agencies through computer matching programs. Matching programs compare our records with records kept by other Federal, State or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs.

I hereby authorize the United States to furnish to the competent social insurance agency of the other country all of the information and evidence in its possession which relates or could relate to this application for benefits. I also authorize the agency(ies) of the other country to furnish the Social Security Administration or a United States Foreign Service post all of the information and evidence in its possession which relates to this application for benefits.

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE OF APPLICANT	Date (MM/DD/YYYY)
SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink)	Telephone number(s) at which you may be
	contacted during the day (include Area Code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) (Enter resident address in "Remarks" if different)

City and State

ZIP Code

Country (if any) in which you now live

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. Also, print the applicant's name in the Signature block.

1. Signature of Witness

2. Signature of Witness

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

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