A. Item 1 through 3—Name, age and SSN information

Items 1 through 3 are needed for SSN purposes. In addition, the place of birth will also be material to the question of citizenship.

The same development will be followed as with the SSA-1F6 (Application for Retirement Insurance Benefits) where there is a question regarding the proper identification of the claimant (see GN 00203.020).

B. Item 4—Previous filing information

This item will be used to make certain that an individual is not already entitled to HI because he is eligible for RSI or entitled to an RSI or RR benefit. The item is primarily directed at some one who might be an auxiliary or survivor since it may not be possible to pick up prior entitlement by means of the individual's own SSN. If an individual is already entitled to HI because of entitlement to or eligibility for monthly benefits, the SSA-18F5 and related material should be forwarded to the processing center as a duplicate claim. The processing center should notify the individual that he is already entitled to HI; appropriate action will be taken on any SMI election with the duplicate claim.

C. Items 5 through 8—Earnings information

The earnings items are needed to determine whether or not the individual is fully insured for RIB or meets the QC requirement for HI (HI 00801.066).

Items 5 and 6 are the regular RR employment and MS items necessary to determine whether development of RR or MS is required.

Item 7 is a lead question used to elicit information about work under the social security system of a country other than the U.S. If the claimant engaged in covered work in another country, totalized benefits may be payable. However, HI entitlement may not be granted based on totalization if the individual is not insured based on U.S. work alone.

Item 8 asks the amount of total earnings for last year and this year. This item gives sufficient current earnings information to use in determining whether insured status is affected when the earnings record is received.

D. Items 9 and 10—Citizenship and residence requirements

These items pertain to the requirement that the claimant either be a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for 5 years before his first month of entitlement.

E. Items 11 through 13—Marital information

These items aid in determining whether there is eligibility or entitlement on the spouse's E/R and also possible RR entitlement if the claimant's spouse is or was a RR employee (see HI 00801.011 and HI 00801.106). It may also serve as a lead for soliciting a claim from the spouse.

F. Item 14—Preclusion because of the FEHB Act of 1959, as amended

This item is needed to screen out persons who are or could be covered under the FEHB Act of 1959, as amended, and thus may be precluded from entitlement under the HI deemed insured provision. If HI entitlement is precluded because of FEHBA involvement, the SSA-18F5 may be used to enroll for SMI. However, a full explanation of any overlapping coverage which might result from SMI enrollment in addition to the FEHBA medical insurance should be given the claimant.

G. Item 15—Premium-HI enrollment

This item serves as an enrollment request for Premium-HI. If the applicant completes this item during an enrollment period available to him, and he meets all other requirements for entitlement, he will be awarded Premium-HI if he is ineligible for HI under the regular and deemed insured provisions.

H. Item 16—SMI enrollment

This item serves as an enrollment request for SMI if the individual is not eligible for automatic enrollment. If the individual wishes to enroll, the SSA-18F5 becomes an enrollment request provided it is filed during an enrollment period.

I. Item 17—Civil Service annuity

This item asks the claimant whether he or his spouse is receiving an annuity under the Federal Civil Service Retirement Act and if so, asks for the annuity number. In this way, the Civil Service Commission can properly withhold SMI premiums from the annuity check. If the claimant agrees in writing, premiums for the spouse's SMI coverage can be deducted from the civil service annuity check. (See HI 00805.255)