Get SSA FSMSS-118 2012-2024

FSM Social Security Administration P. O. Box L Kolonia Pohnpei FM 96941 Tel. No. 691 320-2708 Fax No. 691 320-2607 E-Mail fsmssa mail.fm FSMSS-118 Sept. Have you remarried yes no 3. Do you have children receiving social security benefits 4. Are any of the children receiving social security benefits married working adopted no longer live with you yes no name of child ss number died Wage Earner s Name IMPORTANT n This survey form must be notarized if not signed in the presence of a representative of the FSMSSA. n If you are living abroad and employed please submit along with this survey form copies of W-2 forms for all years you have been employed. BENEFICIARY S DECLARATION I understand that any false statement or misrepresentation of any fact in maintaining a right for benefits is a crime punishable under Title 53 of the FSM Code. 2012 QUESTIONNAIRE Dear Beneficiary Please complete this survey and submit it to our office as soon as possible. Failure to do so will result in benefit withholding. Thank you. Retirement Disability 1. Are you working now 1. Are you working now yes no If yes since when Date 2. Has your condition improved This section for all* Do not leave blank. Retiree disablility recipient or surviving spouse died Who died print name ss when Surviving Spouse or Guardian skip to item 4 2. Have you remarried yes no 3. Do you have children receiving social security benefits 4. Are any of the children receiving social security benefits married working adopted no longer live with you yes no name of child ss number died Wage Earner s Name IMPORTANT n This survey form must be notarized if not signed in the presence of a representative of the FSMSSA. n If you are living abroad and employed please submit along with this survey form copies of W-2 forms for all years you have been employed* BENEFICIARY S DECLARATION I understand that any false statement or misrepresentation of any fact in maintaining a right for benefits is a crime punishable under Title 53 of the FSM Code. Beneficiary s Printed Name Signature Authorized Representative Relationship to Beneficiary attach authorization slip Beneficiary Current Address How long have you been at this address Telephone No* Cell Phone No* Municipality Interviewer. 2012 QUESTIONNAIRE Dear Beneficiary Please complete this survey and submit it to our office as soon as possible. Failure to do so will result in benefit withholding. Thank you. Retirement Disability 1. Are you working now 1. Failure to do so will result in benefit withholding. Thank you. Retirement Disability 1. Are you working now 1. Are you working now yes no If yes since when Date 2. Has your condition improved This section for all* Do not leave blank. Are you working now yes no If yes since when Date 2. Has your condition improved This section for all* Do not leave blank. Retiree disablility recipient or surviving spouse died Who died print name ss when Surviving Spouse or Guardian skip to item 4 2. Retiree disablility recipient or surviving spouse died Who died print name ss when Surviving Spouse or Guardian skip to item 4 2. Have you remarried yes no 3. Do you have children receiving social security benefits 4. Are any of the children receiving social security benefits married working adopted no longer live with you yes no name of child ss number died Wage Earner s Name IMPORTANT n This survey form must be notarized if not signed in the presence of a representative of the FSMSSA. .