Form SSA-1 Application for Retirement Insurance Benefits

Part C added to
#6; updated the
instruction for
the answer
section of Part B

(c) when were you lawfully admitted to the U.S.?

Instruction deleted

I agree to promptly notify the Social Security Administration if I become entitled to a pension or annuity based on my
employment not covered by Social Security, or if such pension or annuity stops.
Statement added to #15

Revised #17

Added statement at the end of #17
If your claim for retirement benefits is approved, your children (including adopted children, and stepchildren) or
dependent grandchildren (including step-grandchildren) may be eligible for benefits based on your earnings
record.

Revised #18

Instruction deleted

Reworded #27

Modified "Medicare Information" section

Deleted #'s 30 & 31

Updated Privacy Act Statement

See Revised PRA Attached

Added Bullet

Updated Section

Removed "after 1956" from Bullet

Modified Section

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - 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 11
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.