Filing for Benefits or MediCare

Name:
Last Name:
Mailing Address (not in U.S.):
Daytime Phone:
Evening Phone:
Mobile/cell:
Your email address:
Social Security Number:

(Last 4 digits)
Date of birth:
(Optional, see note below)
Are you unable to work because of a disability?
Are you working more than 45 hours per month?
Additional Information:
If You Are Married please also complete
Name of spouse:
Last Name of spouse:
Social Security Number (SSN) of Spouse if they have one:

(Last 4 digits)
Spouse’s Date of Birth:
(Optional, see note below)
Note: Email is not secure and any information you provide on this online inquiry form cannot be guaranteed safe from potential loss. If you choose to send us any Personally Identifiable Information in your email inquiry, it will be removed from the email before we send our reply.

The information you provide is used solely by the Federal Benefits Unit of the U.S. Embassy Madrid. In order to process certain types of requests, we may have to ask for your Social Security Number (SSN) or the last 4-digits thereof, your date of birth, or your banking information. You may decline to provide such information, but that could inhibit our ability to answer your questions or assist you with your request. Any information provided on our web form is not retained and is used only in order to process your current request or answer your current questions. The Madrid FBU Office works in accordance with SSA procedures as well as the Paperwork Reduction Act (44 U.S.C. 3501 et seq.) and the Privacy Act of 1974. You can read our full privacy statement at http://www.socialsecurity.gov
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Emergency Assistance

U.S. Citizens with Emergencies

Please call: (+34) 91 587 2200

Outside of Office Hours, contact: (+34) 91 587 2200

Outside of Spain: (+34) 91 587 2200

Emergency Contact – All Locations Get Travel Alerts International Parental Child Abduction Arrest of a U.S. Citizen Death of a U.S. Citizen Victims of Crime Emergency Financial Assistance

U.S. Embassy & Consulate
in Spain and Andorra

If You Are Married please also complete

U.S. Embassy & Consulate in Spain and Andorra