Current SSA-16-BK

SOCIAL SECURITY ADMINISTRATION

TEL

Form Approved
OMB No. 0960-0060

TOE 120/145

(Do not write in this space)

APPLICATION FOR DISABILITY INSURANCE BENEFITS
I apply for a period of disability and/or all insurance benefits for which I am
eligible under Title II and Part A of Title XVIII of the Social Security Act, as
presently amended.

FIRST NAME, MIDDLE INITIAL, LAST NAME

1. PRINT your name

2.
3.

/

Enter your Social Security Number
Check (X) whether you are

4. If this claim is awarded, do you want a password to use SSA's
Internet/phone service?

/

Male

Female

Yes

No

Answer question 5 if English is not your preferred language. Otherwise, go to item 6.
5.
6.

Enter the language you prefer to: speak

write
MONTH, DAY, YEAR

(a) Enter your date of birth
(b) Enter name of State or foreign country where you were born.

7.

(c) Was a public record of your birth made before you were age 5?

Yes

No

Unknown

(d) Was a religious record of your birth made before you were age 5?

Yes

No

Unknown

(a) Are you a U.S. citizen?

Yes

No

Go to item 8

(b) Are you an alien lawfully present in the U.S.?

Go to item (b)

Yes

No

8. (a) Enter your name at birth if different from item (1)
(b) Have you used any other names?

Yes

No

Go to (c)

(c) Other name(s) used.
9. (a) Have you used any other Social Security number(s)?

Go to item 9

Yes

No

Go to (b)

Go to item 10

(b) Enter Social Security number(s) used.

/

/

10 . Enter the date you became unable to work because of your illness, injuries,
or conditions.
11 . (a) Have you (or has someone on your behalf) ever filed an application for
Social Security benefits, a period of disability under Social Security,
Supplemental Security Income, or hospital or medical insurance under
Medicare?

Yes
No
Unknown
(If "Yes," answer (If "No," or "Unknown,"
(b) and (c).)
go to item 12.)

(b) Enter name of person on whose
Social Security record you filed
the other application.
(c) Enter Social Security Number of person named in (b).
If unknown, check this block.
Form SSA-16-BK (05-2006)
Destroy prior editions

EF (12-2008)

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Answer item 12, if you have been in the military service. Otherwise, go to item 13.
12.

(a) Were you in the active military or naval service (including Reserve or
National Guard active duty or active duty for training) after September
7, 1939 and before 1968?

No
(If "No," go to
item 13.)

FROM: (Month, Year)

(b) Enter dates of service

13.

Yes
(If "Yes," answer
(b) and (c).)

TO: (Month, Year)

(c) Have you ever been (or will you be) eligible for a monthly benefit from
a military or civilian Federal agency? (Include Veterans Administration
benefits only if you waived military retirement pay.)

Yes

No

Have you or your spouse worked in the railroad industry for 5 years or
more?

Yes

No

14. (a) Do you have Social Security credits (for example, based on work or
Yes
residence) under another country's Social Security System?
(If "Yes," answer
(b).)

No
(If "No," go to
item 15.)

(b) List the country(ies):
15. (a) Are you entitled to, or do you expect to become entitled to, a pension or
annuity based on your work after 1956 not covered by Social Security?
(b)

I became entitled, or expect to become entitled, beginning

(c)

I became eligible, or expect to become eligible, beginning

Yes (If "Yes,"
answer (b) and (c).)

No (If "No," go
on to item 16.)

MONTH

YEAR

MONTH

YEAR

I AGREE TO PROMPTLY NOTIFY the Social Security Administration if I become entitled to a pension or annuity
based on my employment after 1956 not covered by Social Security, or if such pension of annuity stops.
16. (a) Have you ever been married?

Yes

No

Go to (b)

Current or
Last
Marriage

Go to item 17

When (Month, day, year)

Where (Name of City and State)

How marriage ended (If still in
effect, write "Not Ended.")

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date of death

(b) To whom married

Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown, so indicate)

/

/

Give the following information about each of your previous marriages. (If none, write ''NONE.'')
(c) To whom married

Your
previous
marriage

When (Month, day, year)

Where (Name of City and State)

How marriage ended

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date of death

Clergyman or public official
Other (Explain in Remarks)
Spouse's Social Security Number (If none or unknown, so indicate)

Use "Remarks" space for information about any other marriages.
Form SSA-16-BK (05-2006)

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17. If your claim for disability benefits is approved, your children (including natural children, adopted children, and
stepchildren) or dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on your earnings
record.
List below: FULL NAME OF ALL such children who are now or were in the past 12 months UNMARRIED and:
 UNDER AGE 18
 AGE 18 TO 19 AND ATTENDING ELEMENTARY OR SECONDARY SCHOOL FULL-TIME
 DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

18. (a) Did you have wages or self-employment income covered under
Social Security in all years from 1978 through last year?

Yes
(If "Yes," go to item 19.)

No
(If "No," answer (b).)

(b) List the years from 1978 through last year in which you did not have
wages or self-employment income covered under Social Security.
19. (a) Enter below the names and addresses of all the persons, companies, or Government agencies for whom you have
worked this year and last year. IF NONE, WRITE "NONE" BELOW AND GO TO ITEM 20.
NAME AND ADDRESS OF EMPLOYER
(If you had more than one employer, please list them
in order beginning with your last (most recent) employer)

Work Began
MONTH

YEAR

Work Ended
(If still working
show "Not Ended")
MONTH

YEAR

(If you need more space, use "Remarks".)
(b) Are you an officer of a corporation or related to an officer of a
corporation?
20. May the Social Security Administration or State agency reviewing
your case, ask your employers for information needed to process the
claim?

Yes

No

Yes

No

Yes

No

21. Complete item 21 even if you were an employee.
(a) Were you self-employed this year or last year?

Go to (b)
(b) Check the year (or years)
you were self-employed

In what type of trade/business
were you self-employed?
(For example, storekeeper, farmer, physician)

Go to item 22

Were your net earnings from the
trade or business $400 or more?
(Check "Yes" or "No")

This year
Yes

Last year

No

22. (a) How much were your total earnings last year? Count both wages and
Amount $
self-employment income. (If none, write "None.")
(b) How much have you earned so far this year? (If none, write
Amount $
"None.")
23. Check if applicable:
Please compute my benefits and complete my claim without using recent earnings that are not yet included on my
(the deceased's, if applicable) earnings record. I understand that the earnings record will be updated automatically within
24 months and that any increase in benefits resulting from these earnings will be paid with the full retroactivity.
Form SSA-16-BK (05-2006)

EF (12-2008)

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24. What are the illnesses, injuries, or conditions that limit your ability to work? (Give a brief description.)

25.

(a) Are you still unable to work because of your illnesses, injuries, or
conditions?
(b) Enter the date you became able to work.

Yes

Go to item 26

No

Go to (b)

MONTH, DAY, YEAR

IMPORTANT INFORMATION ABOUT DISABILITY INSURANCE BENEFITS
PLEASE READ CAREFULLY
SUBMITTING MEDICAL EVIDENCE: I understand that I must provide medical evidence about my
disability and I may be asked to assist the Social Security Administration in obtaining the evidence. I
understand that I may be requested by the State Disability Determination Services to have a
consultative examination at the expense of the Social Security Administration and that if I do not go,
my claim may be denied.
26.

Are your illnesses, injuries, or conditions related to your
work in any way?
27. (a) Have you filed, or do you intend to file, for any other public disability
benefits (including workers' compensation, Black Lung benefits and
SSI)?
(b) The other public disability benefit(s) you have filed (or intend to file)
for is (Check as many as apply):

28.

Yes

No

Yes

No

Go to(b)

Go to item 28

Veterans Administration Benefits

Welfare

Supplemental Security Income (SSI)

Other (If "Other," complete a Workers' Compensation/Public
Disability Benefit Questionnaire)

(a) Did you receive any money from an employer(s) on or after the date
in item 10 when you became unable to work because of your
illnesses, injuries, or conditions? If "Yes", give the amounts and
explain in "Remarks".
(b) Do you expect to receive any additional money from an employer, such
as sick pay, vacation pay, other special pay? If "Yes," please give
amounts and explain in "Remarks".

29. Do you, or did you, have a child under age 3 (your own or your spouse's)
living with you in one or more calendar years when you had no earnings?
30. Do you have a dependent parent who was receiving at least one-half support
from you when you became unable to work because of your disability? If
"Yes," enter the parent's name and address and Social Security number, if
known, in "Remarks".

Yes

No

Yes

No

Yes

No

Yes

No

Amount $

Amount $

31. If you were unable to work before age 22 because of an illness, injury or condition, do you have a parent (including
adoptive or stepparent) or grandparent who is receiving social security retirement or disability benefits or who is
deceased? If yes, enter the name(s) and Social Security number, if known, in "Remarks" (if unknown, write "Unknown").
32. Do you have any unsatisfied felony warrants for your arrest?

Yes

No

33. Do you have any unsatisfied Federal or State warrants for your arrest for
violating the conditions of your probation or parole?

Yes

No

Form SSA-16-BK (05-2006)

EF (12-2008)

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REMARKS (You may use this space for any explanation. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on the form and any accompanying
statements or forms, and it is true and correct to the best of my knowledge.
Date (Month, Day, Year)

SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)

Telephone Number(s) at which you may be contacted
during the day. (Include the area code)

SIGN
HERE

FOR
OFFICIAL
USE ONLY

Routing Transit Number

Direct Deposit Payment Address (Financial Institution)
C/S Depositor Account Number

No Account

Direct Deposit Refused
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)
City and State

ZIP Code

County (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in Signature block.
1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State and ZIP Code)

Address (Number and street, City, State and ZIP Code)

Form SSA-16-BK (05-2006)

EF (12-2008)

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FOR YOUR INFORMATION
An agency in your State that works with us in administering the Social
Security disability program is responsible for making the disability decision
on your claim. In some cases, it is necessary for them to get additional
information about your condition or to arrange for you to have a medical
examination at Government expense.

Collection and Use of Information From Your Application — Privacy Act Notice/Paperwork Act Notice

The Social Security Administration is authorized to collect the information requested on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You
do not have to give us the requested information. However, if you do not provide the information, we will be
unable to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to
benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency for
determining eligibility for a government benefit or program, to a Congressional office requesting information on
your behalf, to an independent party for performance of research and statistical activities, or to the Department of
Justice for use in representing the Federal government.

We may also use this information when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to
find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even
if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available
in Social Security offices. If you want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT

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
20 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM
TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY1-800-325-0778). 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.

Form SSA-16-BK (05-2006)

EF (12-2008)

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RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS
PERSON TO CONTACT ABOUT YOUR CLAIM

SSA OFFICE

DATE CLAIM RECEIVED

TELEPHONE NUMBER (INCLUDE AREA CODE)

Your application for Social Security disability benefits has
been received and will be processed as quickly as possible.

some other change that may affect your claim, you — or
someone for you — should report the change. The changes to
be reported are listed below.

You should hear from us within
days after you have
given us all the information we requested. Some claims may
take longer if additional information is needed.

Always give us your claim number when writing or telephoning
about your claim.

In the meantime, if you change your address, or if there is

If you have any questions about your claim, we will be glad to
help you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID
Change of Marital Status—Marriage, divorce, annulment
of marriage. You must report marriage even if you
believe that an exception applies.

You change your mailing address for checks or
residence. To avoid delay in receipt of checks you
should ALSO file a regular change of address notice
with your post office.

You return to work (as an employee or self-employed)
regardless of amount of earnings.

Your citizenship or immigration status changes.

Your
Your condition
condition improves.
improves.

You go outside the U.S.A. for 30 consecutive days or
longer.
Any beneficiary dies or becomes unable to handle
benefits.

You are under age 65 and you apply for or begin to receive
workers' compensation (including black lung benefits) or
another public disability benefit, or the amount of your
present workers' compensation or public disability benefit
changes or stops, or you receive a lump-sum settlement

Custody Change—Report if a person for whom you are
filing or who is in your care dies, leaves your care or
custody, or changes address.
You are confined to jail, prison, penal institution or
correctional facility for conviction of a crime or you are
confined to a public institution by court order in
connection with a crime.

Text
HOW TO REPORT
You can make your reports by telephone, mail, or in
If person,
you are
awardedyoubenefits,
whichever
prefer. and one or more of
thhange(s) should be reported by:

You become entitled to a pension or annuity based on
your employment after 1956 not covered by Social
Security, or if such pension or annuity stops.

If you are awarded benefits, and one or more of the above
change(s) occur, you should report by:

Your stepchild is entitled to benefits on your record
and you and the stepchild's parent divorce. Stepchild
benefits are not payable beginning with the month
after the month the divorce becomes final.

Calling us TOLL FREE at 1-800-772-1213.
 If you are deaf or hearing impaired, calling us TOLL
FREE at TTY 1-800-325-0778; or
 Calling, visiting or writing your local Social Security
office at the phone number and address above.

You have an unsatisfied warrant for your arrest for a
crime or attempted crime that is a felony (or, in
jurisdictions that do not define crimes as felonies, a
crime that is punishable by death or imprisonment for
a term exceeding 1 year).

For general information about Social Security, visit our
web site at www.socialsecurity.gov.

You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.

Form SSA-16-BK (05-2006)

EF (12-2008)

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