SSA-2512

Pre-1957 Military Service Federal Benefit Questionnaire

Download and Print the SSA-2512

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.
(A) BRANCH OF SERVICE
(B) DATE ACTIVE DUTY BEGAN
MONTH DAY YEAR
(C) DATE SEPARATED FROM ACTIVE DUTY
MONTH DAY YEAR
(D) RATE OR RANK

2. RESERVE SERVICE (OTHER THAN ACTIVE RESERVE DUTY SHOWN ABOVE.)
(A) BRANCH OF SERVICE
(B) DATE MEMBERSHIP BEGAN
MONTH DAY YEAR
(C) DATE MEMBERSHIP ENDED
MONTH DAY YEAR
(D) RATE OR RANK
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
Reserve service -- Payable at age 60
Disability
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
(Over)
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