Current Version of the SSA-1

TEL

TOE 120/145/155

Form Approved
OMB No. 0960-0618

SOCIAL SECURITY ADMINISTRATION

(Do not write in this space)

APPLICATION FOR RETIREMENT INSURANCE BENEFITS
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the
Aged and Disabled) of the Social Security Act, as presently amended.
Supplement. If you have already completed an application entitled "APPLICATION
FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS", you need complete only
the circled items. All other claimants must complete the entire form.
1. (a) PRINT your name

FIRST NAME,

MIDDLE INITIAL,

LAST NAME

Male

(b) Check (X) whether you are

Female

2. Enter your Social Security number

-

-

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

Yes

No

Answer question 4 if English is not your language preference. Otherwise, go to item 5.
4. Enter the language you prefer to:

Write

Speak

Month,

5.

Day,

Year

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

6.

(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 (b).)

(Go to
item 8.)
(b) Are you an alien lawfully present in U.S.?
FIRST NAME,

7.

No

Yes
MIDDLE INITIAL,

LAST NAME

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

Yes
(Go to
item (b).)

No
(Go to
item 9.)

Yes
(Go to
item (b))

No
(Go to
item 10.)

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

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

-

Form SSA-1-BK (3-2006) ef (03-2006)
Destroy prior editions

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(Over)

Do not answer question 10 if you are one year past full retirement age or older; go to question 11.
10. (a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?

(a) Have you (or has someone on your behalf) ever filed an application
for Social Security, Supplemental Security Income, or hospital or
medical insurance under Medicare?
(b) Enter name of person(s) on whose Social Security record
you filed other application.

No

MONTH,

(b) If "Yes", enter the date you became unable to work.

11.

Yes
DAY,

YEAR

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

No
(If "No," go
to item 12.)

Unknown
(If "Unknown,"
go to item 12.)

FIRST NAME, MIDDLE INITIAL, LAST NAME

(c) Enter Social Security number(s) of person named in (b).
(If unknown, so indicate.)

-

-

If you are now AGE 62 or older, or you will be AGE 62 in this month or one of the next 4
months, answer question 12. Otherwise, go to question 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?

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

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

Month, Year

(b) Enter date(s) of service

From:

(c) Have you ever been (or will you be) eligible for monthly
benefits from a military or civilian Federal agency? (including
Veterans Administration benefits only if you waived
Military retirement pay)
13. Did you or your spouse (or prior spouse) work in the railroad
industry for 5 years or more?

14. (a) Do you (or your spouse) have Social Security credits (for example
based on work or residence) under another country's Social
Security system?

Month, Year
To:

Yes

No

Yes

No

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

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

(b) List the country(ies):
(c) Are you (or your spouse) filing for foreign Social Security benefits?

Yes

No

Answer question 15 only if you were born January 2, 1924, or later. Otherwise go on to question 16.
15. (a) Are you entitled to, or do you expect to be 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

Form SSA-1-BK (3-2006) ef (03-2006)

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Yes

No

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

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

MONTH

YEAR

MONTH

YEAR

Yes

16. Have you been married?

(If "Yes," answer
item 17.)

No

(If "No," go to
item 18.)

17. (a) Give the following information about your current marriage. If not currently married, show your last marriage here:
When (Month, day, year)

Where (Name of City and State)

How marriage ended (If still in effect, When (Month, day, year)
write "Not Ended.")

Where (Name of City and State)

Marriage performed by:
Clergyman or public official

If spouse deceased, give date of death

To whom married

Current
or last
marriage

Spouse's date of birth (or age)

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

(b) Give the following information about each of your previous marriages. (IF NONE, WRITE "NONE")
To whom married

How marriage ended

Your
previous
marriage
(Use a separate Marriage performed by:
statement for
Clergyman or public official
information
Other (Explain in Remarks)
about any
other
marriages.)

When (Month, day, year)

Where (Name of City and State)

When (Month, day, year)

Where (Name of City and State)

Spouse's date of birth (or age)

If spouse deceased, give date of death

Spouse's Social Security Number (If none or unknown, so indicate)

18. List below FULL NAME OF ALL your children (including natural children, adopted children, and stepchildren) or
dependent grandchildren (including stepgrandchildren) who are now or were in the past 6 months UNMARRIED and:

·
·

UNDER AGE 18

·

AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL

DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

Also list any student who is between the ages of 18 to 23 if such student was both: 1. Previously entitled to Social
Security benefits on any Social Security record for August 1981; and 2. In full-time attendance at a post-secondary
school prior to May 1982.
(IF THERE ARE NO SUCH CHILDREN, WRITE "NONE" BELOW AND GO ON TO ITEM 19.)

Form SSA-1-BK (3-2006) ef (03-2006)

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(Turn to Page 4)

19.

(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 20.)

No
(If "No," answer
item (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.
20. (a) Enter below the names and addresses of all the persons, companies, or government agencies for whom you

have worked this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO
ITEM 21.
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 Ended (If still
working,
show "Not Ended")

Work Began
Month

Year

Month

Year

(If you need more space, use "Remarks".)
(b) Are you an officer of a corporation, or are you related to an officer of a
corporation?

Yes

No

Yes

No

21.
May we ask your employers for wage information needed to process your
claim?
22. THIS ITEM MUST BE COMPLETED, EVEN IF YOU ARE AN EMPLOYEE.
(a) Were you self-employed this year and/or last year?
(b) Check the year or
years in which you
were self-employed

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

Yes

No

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

(If "No,"
go to item 23.)

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

This year

Yes

No

Last year

Yes

No

23.
Amount

(a) How much were your total earnings last year?

$

(b)
NONE

Place an "X" in each block for EACH MONTH of last year in which you did not earn
more than *$
in wages, and did not perform substantial services in
self-employment. These months are exempt months. If no months were exempt
months, place an "X" in "NONE". If all months were exempt months, place an "X" in
"ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

24.
(a) How much do you expect your total earnings to be this year?

Amount

(b) Place an "X" in each block for EACH MONTH of this year in which you did not or will
not earn more than *$
in wages, and did not or will not perform
substantial services in self-employment. These months are exempt months. If no
months are or will be exempt months, place an "X" in "NONE". If all months are or
will be exempt months, place an "X" in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".
Form SSA-1-BK (3-2006) ef (03-2006)

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$

NONE

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

Answer this item ONLY if you are now in the last 4 months of your taxable year (Sept., Oct., Nov., and Dec., if
your taxable year is a calendar year).
$
25. (a) How much do you expect to earn next year?
Amount
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
expect to earn more than *$
in wages, and do not expect to perform
substantial services in self-employment. These months will be exempt months. If
no months are expected to be exempt months, place an "X" in "NONE". If all
months are expected to be exempt months, place an "X" in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Your
Earnings Affect Your Benefits".
26.

NONE

ALL

Jan.

Feb.

Mar.

Apr.

May

Jun.

Jul.

Aug.

Sept.

Oct.

Nov.

Dec.

If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15), enter here the
month your fiscal year ends.
(Month)

DO NOT ANSWER ITEM 27 IF YOU ARE FULL RETIREMENT AGE AND 6 MONTHS OR OLDER; GO TO ITEM 28.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF THE FOLLOWING
ITEMS:
27. (a) I want benefits beginning with the earliest possible month that will be the most
advantageous.
(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with
the earliest possible month that will be the most advantageous providing there is no
permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with
. I understand that either a higher initial payment or a higher
continuing monthly benefit amount may be possible, but I choose not to take it.

MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, you will automatically receive Medicare Part A (Hospital
Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic enrollment in Medicare
Part B, this application may be used for voluntary enrollment.

COMPLETE ITEM 28 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
In most cases, Medicare does not pay for health care you get while traveling outside the United States. Your local Social Security
office will be glad to explain more about Medicare.
Enrollment in Medicare Part B (Medical Insurance): Medicare Part B helps cover doctor's services and outpatient care. It also covers
some other services that Medicare Part A doesn't cover. Once you are enrolled in Medicare Part B, you will have to pay a monthly
premium. The date your Medicare Part B begins and the amount of the premium you must pay depends on the month you filed this
application with the Social Security Administration. Your premiums will be deducted from any monthly Social Security, Railroad
Retirement, or Office of Personnel Management benefit check you receive. If you do not receive such benefits, you will be notified
how to pay your premiums. You will get advance notice if there is any change in your premium amount.
If you do not enroll in Medicare Part B now, you can enroll later only during a specified enrollment period. If you enroll later, your
coverage may be delayed and you may have to pay a higher premium.

28. Do you want to enroll in Medicare Part B (Medical insurance)?

Yes

No

29. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for
Supplemental Security Income?

Yes

No

30. Do you have any unsatisfied felony warrants for your arrest?

Yes

No

31. 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-1-BK (3-2006) ef (03-2006)

Page 5

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

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives false or
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may
be sent to prison, or face other penalties, or both.
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

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 who know the applicant must
sign below, giving their full addresses. Also, print the applicant's name in the 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-1-BK (3-2006) ef (03-2006)

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RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY RETIREMENT INSURANCE BENEFITS
BEFORE YOU RECEIVE A
NOTICE OF AWARD
TELEPHONE NUMBER(S) TO
CALL IF YOU HAVE A
QUESTION OR SOMETHING
TO REPORT

(

)

SSA OFFICE

DATE CLAIM RECEIVED

-

AFTER YOU RECEIVE A
NOTICE OF AWARD

(

)

there is some other change that may affect your
claim, you—or someone for you—should report the
change. The changes to be reported are listed on
page 8.

Your application for Social Security benefits has been
received and will be processed as quickly as possible.
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.
If you have any questions about your claim, we will be
glad to help you.

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

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

Collection and Use of Information From Your Application—Privacy Act Notice/Paperwork
Reduction 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 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 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 10.5
minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING 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. 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-1-BK (3-2006) ef (03-2006)

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CHANGES TO BE REPORTED AND HOW TO REPORT
Failure to report may result in overpayments that must be repaid, and in possible monetary penalties
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.)

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.

Your citizenship or immigration status changes.

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 go outside the U.S.A. for 30 consecutive days or
longer.

Change of Marital Status - Marriage, divorce,
annulment of marriage.

Any beneficiary dies or becomes unable to handle
benefits.

You can make your reports by telephone, mail, or in
person, whichever you prefer.

Work Changes -- On your application you told us you
expect total earnings for
to be

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

HOW TO REPORT

$
You
than $

(Year)

.
(are)

(are not) earning wages of more
a month.

(are)
(are not) self-employed rendering
You
substantial services in your trade or business.

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
shown on your claim receipt.

(Report AT ONCE if this work pattern changes)
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.
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).
You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.
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.

For general information about Social Security, visit
our web site at www.socialsecurity.gov.
For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable
year in which you earn more than the annual
exempt amount. You may contact SSA to file a
report. Otherwise, SSA will use the earnings
reported by your employer(s) and your
self-employment tax return (if applicable) as the
report of earnings required by law, to adjust benefits
under the earnings test. It is your responsibility to
ensure that the information you give concerning
your earnings is correct. You must furnish
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
BEFORE YOU ANSWER QUESTION 27.
If you are under full retirement age, retirement benefits cannot be payable to you for any month before the month in
which you file your claim.
If you are over full retirement age, retirement benefits may be payable to you for some months before the month in
which you file this claim (but not before the month you attain full retirement age).
If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not
actually receive your full benefit amount for one or more months before full retirement age because benefits are
withheld due to your earnings, your benefit will be increased at full retirement age to give credit for this withholding.
Thus, your benefit amount at full retirement age will be reduced only if you receive one or more full benefit payments
prior to the month you attain full retirement age.
Form SSA-1-BK (3-2006) ef (03-2006)

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