Form SSA-3368 Disability Report - Adult -- Revised Version

DISABILITY REPORT ADULT
SSA-3368-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The information you give us on this report will be used by the office that makes the disability
decision on your disability claim. Completing this report accurately and completely will help us
expedite your claim. Please complete as much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask
your health care provider to complete this report. If you cannot complete the report, a Social
Security Representative will assist you. If you have an appointment, please have the
completed report ready when we contact you. If we ask you to do so, please mail the
completed report to us ahead of time.
Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT
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Print or write clearly.
Include a ZIP or postal code with each address.
Provide complete phone numbers including area code. If a phone number is outside the
United States, also provide international direct dialing (IDD) code and country code.
If you cannot remember the names and addresses of your health care providers, you may
be able to get that information from the telephone book, Internet, medical bills,
prescriptions, or prescription medicine containers.
ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know an
answer, or the answer is "none" or "does not apply," please write: "don't know," or "none,"
or "does not apply."
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any question, please use Section 11 – Remarks on the
last page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS

If you have any of your medical records, send or bring them to our office with this completed
report. Please tell us if you want to keep your records so we can return them to you. If you are
having an interview in our office, bring your medical records, your prescription medicine
containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records.
The information that you give us on this report tells us where to request your medical and other
records.

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WHAT WE MEAN BY “DISABILITY”
“Disability” under Social Security is based on your inability to work. For purposes of this claim, we want
you to understand that “disability” means you are unable to work as defined by the Social Security Act.
You will be considered disabled if you are unable to do any kind of work for which you are suited and if
your disability is expected to last (or has lasted) for at least a year or is expected to result in death. So
when we ask “when did you become unable to work,” we are asking when you became disabled as
defined by the Social Security Act.

The Privacy Act
Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act, as amended, authorize us to collect
this information. The information you provide will be used to make a decision on the named claimant’s
claim. While giving us the information on this report is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant’s claim. We
generally use the information you supply for the purpose of making decisions regarding claims.
However, we may use it for the administration and integrity of Social Security programs. We may also
disclose information to another person or to another agency in accordance with approved routine uses,
which include but are not limited to the following: (1) to enable a third party or agency to assist Social
Security in establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal
Laws requiring the release of information about Social Security records (e.g., to the Government
Accountability Office and the Department of Veterans Affairs); (3) to make determinations for eligibility
in similar health and income maintenance programs at the Federal, State, and local level; and, (4) to
facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for
Federally-funded or administered benefit programs and for repayment of payments or delinquent debts
under these programs.
.Additional information regarding this form, routine uses of information, and our programs and systems,
is available on-line at www.socialsecurity.gov or at any local Social Security office.

The Paperwork Reduction Act
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 60 minutes
to read the instructions, gather the facts, and answer the questions. You may send comments on our
time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed report.
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, THE
NEAREST U.S EMBASSY OR CONSULATE OFFICE. Office addresses are listed under U.S.
Government agencies in your telephone directory or you may call 1-800-772-1213 (TTY 1-800325-0778) for the address.
Additional information regarding this report, routine uses of information, and our programs and systems,
is available on-line at www.socialsecurity.gov or at any local Social Security office.

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS

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Social Security Administration

Form Approved OMB No. xxxx-xxxx
For SSA Use Only- Do not write in this box.

DISABILITY REPORT
ADULT

Related SSN

___________________________

Number Holder ___________________________
If you are filling out the report for someone else, please provide information about him or her. When a
question refers to “you” or “your,” it refers to the person who is applying for disability benefits.
Section 1 – Information About the Disabled Person
1.A Name (First, Middle Initial, Last)
1.B Social Security Number
1.C Mailing Address (Street or PO Box) Include apartment number or unit if applicable.

City

State/Province

ZIP/Postal Code

Country (if not USA)

1.D Email Address
1.E Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA or
Canada.
Phone number ______________________________
 Check this box if you do not have a phone or a number where we can leave a message.
1.F Alternate Phone Number – another number where we may reach you, if any
Alternate phone number ______________________________
1.G Can you speak and understand English?  Yes  No
If no, what language do you prefer? _____________________________
If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.H Can you read and understand English?  Yes
 No
1.I Can you write more than your name in English?

 Yes

 No

1.J Have you used any other names on your medical or educational records? Examples are maiden name, other
married name, or nickname.  Yes  No
If yes, please list them here:

Section 2 – Contacts
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions,
and can help you with your claim.
2.A Name (First, Middle Initial, Last)
2.B Relationship to you
2.C Daytime Phone Number (as described in 1.E above)
2.D Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City

State/Province

2.E Can this person speak and understand English?

 Yes

ZIP/Postal Code

Country (if not USA)

 No

If no, what language is preferred? ______________________________

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Section 2 – Contacts (continued)
2.F Who is completing this report?
 The person who is applying for disability (Go to Section 3 – Medical Conditions)
 The person listed in 2.A (Go to Section 3 – Medical Conditions)
 Someone else (Complete the rest of Section 2 below)
2.G Name (First, Middle Initial, Last)
2.H Relationship to Person Applying
2.I Daytime Phone Number
2.J Mailing Address (Street or PO Box) Include apartment number or unit if applicable.

City

State/Province

ZIP/Postal Code

Country (if not USA)

Section 3 – Medical Conditions
3.A List all of the physical or mental conditions (including emotional or learning problems) that limit your ability
to work. If you have cancer, please include the stage and type. List each condition separately.

1.
2.
3.
4.
5.
If you need more space, go to Section 11 on the last page
3.B What is your height without shoes?

_____
_______
OR __________
feet
inches
centimeters (if outside USA)
3.C What is your weight without shoes? _______
OR _________
pounds
kilograms (if outside USA)
3.D Do your conditions cause you pain or other symptoms?  Yes
 No
Section 4 – Work Activity
4.A Are you currently working?
 No, I have never worked (Go to question 4.B below)
 No, I have stopped working (Go to question 4.C below)
 Yes, I am currently working (Go to question 4.F on page 5)
IF YOU HAVE NEVER WORKED:
4.B When do you believe your condition(s) became severe enough to keep you from working (even though you
have never worked)? (month/day/year) ______/_____/_____ (Go to Section 5 on Page 5)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year) ______/_____/_____
Why did you stop working?
 Because of my condition(s).
 Because of other reasons. Please explain why you stopped working (for example: laid off, early
retirement, seasonal work ended, business closed)
________________________________________________________________________________
________________________________________________________________________________
Even though you stopped working for other reasons, when do you believe your condition(s) became
severe enough to keep you from working? (month/day/year) ______/_____/_____
4.D Did your condition(s) cause you to make changes in your work activity? (for example, job duties, hours or rate
of pay)
 No (Go to Section 5 – Education and Training on page 5)
 Yes When did you make changes? (month/day/year) ______/_____/_____

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4.E Since the date in 4.D above, have you had gross earnings greater than $980 in any month? Do not count sick
leave, vacation, or disability pay. (We may contact you for more information.)
 No (Go to Section 5 on page 5)
 Yes (Go to Section 5 on page 5)
IF YOU ARE CURRENTLY WORKING:
4.F Has your condition(s) caused you to make changes in your work activity? (for example: job duties or hours)
 No When did your condition(s) first start bothering you? (month/day/year) ______/_____/_____
 Yes When did you make changes? (month/day/year) ______/_____/_____
4.G Since your condition(s) first bothered you, have you had gross earnings greater than $980 in any month? Do
not count sick leave, vacation, or disability pay. (We may contact you for more information.)
 No
 Yes
Section 5 – Education and Training
5.A Circle the highest grade of school completed.
0

1

2

3

4

5

6

7

8

9

10

11

12

GED

College:
1 2 3

4 or more

Date completed: ______________________
5.B Did you attend special education classes?

 Yes

 No (Go to 5.C)

Name of school _______________________________________________________
City _____________________________

State/Province _____ Country (if not USA)____________

Dates attended special education classes: from ________________ to ________________
5.C. Have you completed any type of specialized job training, trade, or vocational school?  Yes

 No

If “Yes”, what type? _______________________ Date completed _______________________
If you need to list other education or training use Section 11 – Remarks on the last page
Section 6 – Job History
6.A List the jobs (up to 5) that you have had in the 15 years before you became unable to work because of your
physical or mental conditions. List your most recent job first.
 Check here and go to page 7 if you did not work at all in the 15 years before you became unable to work.
Dates Worked
Hours
Days
Rate of Pay
From
To
Per
Per
Job Title
Type of Business
Day
Week Amount Frequency
mm/yy mm/yy
1.
2.
3.
4.
5.

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Check the box below that applies to you.

 I had only one job in the last 15 years before I became unable to work. Answer the questions below.
 I had more than one job in the last 15 years before I became unable to work. Do not answer the questions
on this page; go to Section 7 on page 7. (We may contact you for more information.)

Section 6 – Job History (continued)
Do not complete this page if you had more than one job in the last 15 years before you became unable to work.
6.B Describe this job. What did you do all day?

(If you need more space, use Section 11 – Remarks, on the last page.)
6.C In this job, did you:
Use machines, tools, equipment?
 Yes
 No
Use technical knowledge or skills?  Yes
 No
Do any writing, complete reports, or perform any duties like this?  Yes
 No
6.D In this job, how many total hours each day did you do each of the tasks listed:
Task
Hours
Task
Hours
Task
Walk
Stoop (Bend down & forward at the waist)
Handle large objects
Stand

Kneel (Bend legs to rest on knees)

Sit

Crouch (Bend legs & back down & forward)

Climb

Crawl (Move on hands & knees)

Hours

Write, type or handle
small objects,
Reach

6.E Lifting and carrying (Explain in the box below, what you lifted, how far you carried it, and how often you did
this in your job):

6.F Check the heaviest weight lifted:
Less than 10 lbs. ____ 10 lbs.____

20 lbs.____

50 lbs.____

100 lbs. or more ____ Other ____

6.G Check weight frequently lifted: (by frequently, we mean from 1/3 to 2/3 of the workday.)
25 lbs.____
50 lbs. or more ____ Other ____
Less than 10 lbs. ____ 10 lbs.____
6.H Did you supervise other people in this job?  Yes (complete items below)
How many people did you supervise? _______
What part of your time did you spend supervising people? ______
Did you hire and fire employees?
6.I Were you a lead worker?

 Yes

 Yes

 No (go to 6.I)

 No

 No

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Section 7 – Medicines
7. Are you taking any medicines (prescription or non-prescription)?
 Yes (Give the information requested below. You may need to look at your medicine containers.)
 No (Go to Section 8 – Medical Treatment)
Name of Medicine

If prescribed, give name of doctor

Reason for medicine

If you need to list other medicines use Section 11 – Remarks on the last page.
Section 8 – Medical Treatment
Have you seen a doctor or other health care professional or received treatment at a hospital or clinic, or do you
have a future appointment scheduled?
8.A For any physical condition(s)?

□ Yes
□ No
8.B For any mental condition(s) (including emotional or learning problems)?

□ Yes
□ No
If you answered “No” to both 8.A and 8.B, go to
Section 9 – Other Medical Information on page 13

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Section 8 – Medical Treatment (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
8.C Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Mailing Address
City

Patient ID# (if known)

State/Province

ZIP/Postal Code

Country (if not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit ___________

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

Last Visit ___________

A. ________________

A. Date in ______ Date out ______

Next scheduled appointment

B. ________________

B. Date in ______ Date out ______

(if any) _____________

C. ________________

C. Date in ______ Date out ______

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Check the boxes below for any tests this provider performed or sent you to, or has scheduled you to take. Please
give the dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last
page.
 Check this box if no tests by this provider or at this facility.
Kind of Test
 EKG (heart test)

Dates of Tests

Kind of Test
 EEG (brain wave test)

 Treadmill (exercise test)

 HIV Test

 Cardiac Catheterization

 Blood Test (not HIV)

 Biopsy (list body part)
____________________
 Hearing Test

 X-Ray (list body part)
_____________________

 Speech/Language Test
 Vision Test
 Breathing Test

Dates of Tests

 MRI/CT Scan (list body part)
______________________
 Other (please describe)
_______________________

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 13.

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Section 8 – Medical Treatment (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
8.D Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Mailing Address
City

Patient ID# (if known)

State/Province

ZIP/Postal Code

Country (if not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit ___________

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
A. Date in ______ Date out ______

Last Visit ___________

A. ________________

Next scheduled appointment

B. ________________

(if any) _____________

C. ________________

B. Date in ______ Date out ______
C. Date in ______ Date out ______

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
 Check this box if no tests by this provider or at this facility.
Kind of Test
 EKG (heart test)

Dates of Tests

Kind of Test
 EEG (brain wave test)

 Treadmill (exercise test)

 HIV Test

 Cardiac Catheterization

 Blood Test (not HIV)

 Biopsy (list body part)
____________________
 Hearing Test

 X-Ray (list body part)
_____________________

 Speech/Language Test
 Vision Test
 Breathing Test

Dates of Tests

 MRI/CT Scan (list body part)
______________________
 Other (please describe)
_______________________

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 13.

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Section 8 – Medical Treatment (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
8.E Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Mailing Address
City

Patient ID# (if known)

State/Province

ZIP/Postal Code

Country (if not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit ___________

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
A. Date in ______ Date out ______

Last Visit ___________

A. ________________

Next scheduled appointment

B. ________________

(if any) _____________

C. ________________

B. Date in ______ Date out ______
C. Date in ______ Date out ______

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
 Check this box if no tests by this provider or at this facility.
Kind of Test
 EKG (heart test)

Dates of Tests

Kind of Test
 EEG (brain wave test)

 Treadmill (exercise test)

 HIV Test

 Cardiac Catheterization

 Blood Test (not HIV)

 Biopsy (list body part)
____________________
 Hearing Test

 X-Ray (list body part)
_____________________

 Speech/Language Test
 Vision Test
 Breathing Test

Dates of Tests

 MRI/CT Scan (list body part)
______________________
 Other (please describe)
_______________________

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 13.

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Section 8 – Medical Treatment (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
8.F Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Mailing Address
City

Patient ID# (if known)

State/Province

ZIP/Postal Code

Country (if not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit ___________

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
A. Date in ______ Date out ______

Last Visit ___________

A. ________________

Next scheduled appointment

B. ________________

(if any) _____________

C. ________________

B. Date in ______ Date out ______
C. Date in ______ Date out ______

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
 Check this box if no tests by this provider or at this facility.
Kind of Test
 EKG (heart test)

Dates of Tests

Kind of Test
 EEG (brain wave test)

 Treadmill (exercise test)

 HIV Test

 Cardiac Catheterization

 Blood Test (not HIV)

 Biopsy (list body part)
____________________
 Hearing Test

 X-Ray (list body part)
_____________________

 Speech/Language Test
 Vision Test
 Breathing Test

Dates of Tests

 MRI/CT Scan (list body part)
______________________
 Other (please describe)
_______________________

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 13.

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Section 8 – Medical Treatment (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you have
one scheduled.
8.G Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code

Country (if not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit ___________

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
A. Date in ______ Date out ______

Last Visit ___________

A. ________________

Next scheduled appointment

B. ________________

(if any) _____________

C. ________________

B. Date in ______ Date out ______
C. Date in ______ Date out ______

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
 Check this box if no tests by this provider or at this facility.
Kind of Test
 EKG (heart test)

Dates of Tests

Kind of Test
 EEG (brain wave test)

 Treadmill (exercise test)

 HIV Test

 Cardiac Catheterization

 Blood Test (not HIV)

 Biopsy (list body part)
____________________
 Hearing Test

 X-Ray (list body part)
_____________________

 Speech/Language Test
 Vision Test
 Breathing Test

Dates of Tests

 MRI/CT Scan (list body part)
______________________
 Other (please describe)
_______________________

If you have been treated by more than five doctors or hospitals, use Section 11 – Remarks
on the last page and give the same detailed information as above for each healthcare provider.

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Section 9 – Other Medical Information
9. Does anyone else have medical information about any of your physical and/or mental condition(s) (including
emotional and learning problems), or are you scheduled to see anyone else? (This may include places such as
workers’ compensation, vocational rehabilitation, insurance companies who have paid you disability benefits,
prisons, attorneys, social service agencies and welfare.)

□
□

Yes (Please complete information below.)

No (If you are receiving Supplemental Security Income (SSI) and have been asked to complete
this report, go to Section 10 – Vocational Rehabilitation; if not, go to Section 11 on the last page.)
Name of Organization
Phone Number
Mailing Address
City

State/Province

Name of Contact Person
Date of First Contact

ZIP/Postal Code

Country (if not USA)

Claim or ID Number (if any)
Date of Last Contact

Date of Next Contact (if any)

Reasons for Contacts

If you need to list other people or organizations use Section 11 – Remarks on the last page and give the
same detailed information as above for each one you list.
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI.
Section 10 – Vocational Rehabilitation, Employment, or Other Support Services
10.A Have you participated, or are you participating in:
 An individual work plan with an employment network under the Ticket to Work Program;
 An individualized plan for employment with a vocational rehabilitation agency or any other organization;
 A Plan to Achieve Self Support (PASS);
 An individualized education program (IEP) through a school (if a student age 18 – 21); or
 Any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?

□
□

Yes (Complete the following information)

No (Go to Section 11 on the next page)
10.B Name of Organization or School
Name of Counselor, Instructor, or Job Coach

Phone Number

Mailing Address
City

State/Province

ZIP/Postal Code

10.C When did you start participating in the plan or program?

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Country (if not USA)

__________________________

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10.D Are you still participating in the plan or program?

□ Yes. I am scheduled to complete the plan or program on: _______________________
□ No. I completed the plan or program on: ______________________
□ No. I stopped participating in the plan or program before completing it because: ____________________
__________________________________________________________________________________
10.E List the types of services, tests, or evaluations that you received (for example: intelligence or psychological
testing, vision or hearing test, physical exam, work evaluations, or classes).

If you need to list another plan or program use Section 11 – Remarks and give the same detailed
information as above.
Section 11 – Remarks
Please write any additional information you did not give in earlier parts of this report. If you did not have enough
space in the sections of this report to write the requested information, please use this space to tell us the
additional information requested in those sections. Be sure to show the section to which you are referring.

Date Report Completed

► ___/___/______
(Month)

SSA 3368-BK Draft v06/25/2009 Destroy prior versions

(Day)

(Year)

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