Form SSA-16 Application for Disability Insurance Benefits

SOCIAL SECURITY ADMINISTRATION

TEL

Form Approved
OMB No. 0960-0618

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
X

2.
3.

Enter your Social Security Number

X

Check (X) whether you are

X

/
Male

4. If this claim is awarded, do you want a password to use SSA's
Yes
Internet/phone service?
5.
Answer question 45 if English is not your preferred language. Otherwise, go to item 6.
4.5. Enter the language you prefer to: Speak
Write

Female
No

MONTH, DAY, YEAR

5.6. (a) Enter your date of birth

X

(b) Enter
Enter name
nameofofcity
State
foreign
country
wherewhere
you were
born.born.
andorstate,
or foreign
country
you were

6.7.

/

X

(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?

No

Yes

X

Go to item 78

No

Yes

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

Go to item (b)

Go to item (c)

7
Go to item 8

(c) When were you lawfully admitted to the U.S.?
8. (a) Enter your name at birth if different from item (1)
7.
(b) Have you used any other names?

X

Yes

No

Go to item 98

Go to (c)
(c) Other name(s) used.
9. (a) Have you used any other Social Security number(s)?
8.

X

Yes

No
9
Go to item 10

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

X

/

/

10.
date
you became
unablebecame
to work
because
of to
your
injuries,
When the
do you
believe
your condition(s)
severe
enough
keepillness,
you from
9. Enter
or
conditions.
working
(even if you have never worked)? ------------------------------------------------------->X
11.
10. (a) Have you (or has someone on your behalf) ever filed an application for
No
Unknown
Yes
Social Security benefits, a period of disability under Social Security, (If "Yes," answer
(If "No," or "Unknown,"
Supplemental Security Income, or hospital or medical insurance under
(b) and (c).)
go to item 12.)
11.)
X
Medicare?
(b) Enter name of person on whose
Social Security record you filed
the other application.
X
(c) Enter Social Security Number of person named in (b).
If unknown, check this block.
Form SSA-16-BK (12-2010) EF(12-2010)
Destroy prior editions

Page 1

X

/

/

12.
11.

(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?

X

(b) Enter dates of service

X

(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
(If "Yes," answer
(b) and (c).)
FROM: (Month, Year)

X

13. Have
youoror
your
spouse
in the work
railroad
industry
5 years
Did you
your
spouse
(orworked
prior spouse)
in the
railroadfor
industry
foror5
12.
more?
years or more?

X

14. (a) Do you have Social Security credits (for example, based on work or residence)
13.
under another country's Social Security System?

(b) List the country(ies):

No
(If "No," go to item
13.)
12.)
TO: (Month, Year)

Yes

No

Yes

No
No
(If "No," go to item
15.)
14.)

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

X

X

Are you
you entitled
expect
to to
be become
entitled to,
a pension
annuityor
(or a lump
15.
14. (a) Are
entitledto,
to,orordodoyou
you
expect
entitled
to, aorpension

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

sum in place
a pension
or annuity)
based
your work
after 1956
not covered by
annuity
basedofon
your work
after 1956
noton
covered
by Social
Security?
Social Security?

(b)

I became entitled, or expect to become entitled, beginning

X

(c)

I became eligible, or expect to become eligible, beginning

X

No (If "No,"
go on to item 16.)
15.)

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 not covered by Social Security, or if such pension or annuity stops.
16.
15. (a) Have you ever been married?

No
Yes
Go to item 17
Go to (b)
16
(b) Give the following information about your current marriage. If not currently married, write "None". ___________________Go on to item
16(c)
15(c)
X

Spouse's name (including maiden name)
Marriage performed by:

Where (Name of City and State)

When (Month, day, year)

Spouse's date of birth (or age)

Clergyman or public official
Other (Explain in Remarks)

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

/

/

(c) Enter information about any other marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or

•

Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the combined period
of marriage totaled 10 years or more. If none, write "None"__________. Go on to item 15(d)
16(d) if you have a child(ren) who is under age
16 or disabled or handicapped (age 16 or over and disability began before age 22) and you are divorced from the child's other parent
who is now deceased and the marriage lasted less than 10 years.

Spouse's name (including maiden name)

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:
Clergyman or public official
Other (Explain in Remarks)

Spouse's date of birth If spouse deceased, give Spouse's Social Security Number (If none or unknown,
(or age)
date of death
so indicate)

/

/

(d) Enter information about any marriage if you:
• Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22); and
• Were married for less than 10 years to the child's mother or father, who is now deceased; and
• The marriage ended in divorce
If none, write "None" _____________.
Spouse's name (including maiden name)
Date of divorce (Month, day, year)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)

When (Month, day, year)
Where (Name of City and State)

Spouse's date of birth Date of spouse's death
(or age)

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

/

Use the "REMARKS" space on page 5 for marriage continuation or explanation.
Form SSA-16-BK (12-2010) EF(12-2010)

Where (Name of City and State)

Page 2

/

17.
16.

If your claim for disability benefits is approved, your children (including 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
17.
Social Security in all years from 1978 through last year?

Yes
(If "Yes," go to item 19.)
18.)

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
18.
19.
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
19.
your case, ask your employers for information needed to process the
claim?
20 even if you were an employee.
21. Complete item 21
20.
(a) Were you self-employed this year or last year?
(b) Check the year (or years)
you were self-employed

X

Yes

No

Yes

No

X

X

Yes

Go to (b)

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

No
21
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

22. (a) How much were your total earnings last year? Count both wages and
21.
X Amount $
self-employment income. (If none, write "None.")
(b) How much have you earned so far this year? (If none, write
X Amount $
"None.")
Form SSA-16-BK (12-2010) EF(12-2010)

Page 3

No

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

24.
22.
(a) Are you still unable to work because of your illnesses, injuries, or
conditions?
(b) Enter the date you became able to work.

Yes
X

23
Go to item 25

X

MONTH, DAY, YEAR

No

Go to (b)

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.
25.
23.

Are your illnesses, injuries, or conditions related to your
work in any way?

X

26. (a) Have you filed, or do you intend to file, for any other public disability
24.
benefits (including workers' compensation, Black Lung benefits and
SSI)?

Yes
Yes

Go to(b)

X

No
No

Go to item 27
25

(b) The other public disability benefit(s) you have filed (or intend to file)
for is (Check as many as apply):

27.
25.

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
9 when you became unable to work because of your
in item 10
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".

X

X

28. Do you, or did you, have a child under age 3 (your own or your spouse's)
26.
living with you in one or more calendar years when you had no earnings?
29. Do you have a dependent parent who was receiving at least one-half support
27.
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 $

30. If you were unable to work before age 22 because of an illness, injury or condition, do you have a parent (including
28.
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").

Form SSA-16-BK (12-2010) EF(12-2010)

Page 4

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)

SIGN
HERE

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

X

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 (12-2010) EF(12-2010)

Page 5

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing
Transit
Number

Account Number

Checking

Enroll in Direct Express

Savings

Direct Deposit Refused

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
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide to determine if you or a dependent are eligible for insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent us
from making an accurate and timely decision concerning your or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than for determining the identity of a spouse. 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 an 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 from Social Security records (e.g., to the Government
Accountability Office and 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, investigative, and audit 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.

See Revised Privacy Act and PRA Statements Attached
Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line
at www.socialsecurity.gov or at your local 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 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 1-800-325-0778). 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 (12-2010) EF(12-2010)

Page 6

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 some other change that may affect your claim, you — or
someone for you — should report the change. The changes to
been received and will be processed as quickly as possible.
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.
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 there is
CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID

X
X
X
X
X
X
X
X
X
X

X

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.

X

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

X

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
confinedto to
jail,
prison,
penal
institution
or
You are
a jail,
prison,
penal
institution
or correctional
correctional
facility
forcontinuous
convictiondays
of for
a conviction
crime or of
you
are or
facility for more
than 30
a crime,
confined
to a public
institution
by court days
ordertoina connection
you are confined
for more
than 30 continuous
public
with a crime.
institution by a court order in connection with a crime.

X
X

You
become entitled
entitled
a pension
or annuity
on your
You become
to atopension,
an annuity,
or abased
lump sum
employment
noton covered
by Social
if such
payment based
your employment
notSecurity,
covered byorSocial
Security,
pension or annuity changes or stops.
or if such pension or annuity stops.

Change of Marital Status—Marriage, divorce, annulment of
marriage.
If you become the parent of a child (including an adopted child)
after you have filed your claim, let us know about the child so
we can decide if the child is eligible for benefits. Failure to
report the existence of these children may result in the loss of
possible benefits to the child(ren).
You return to work (as an employee or self-employed) regardless
of amount of earnings.
Your condition improves.
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.

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

Your stepchild is entitled to benefits on your record and you
and the stepchild's parent divorce. Stepchild benefits are not
If you are awarded benefits, and one or more of the above
payable beginning with the month after the month the divorce
change(s) occur, you should report by:
becomes final.
"my Social
You Security"
Can Do Online" at our web site
• Visiting the section "What
You
You have
have an
an unsatisfied
unsatisfied warrant
warrant for
for more
more than
than 30
30 continuous
continuous days
days for
for your
your
at www.socialsecurity.gov;
You
have
unsatisfied
warrant
forthat
your
forof
crime
arrest
for
crime
or
crime
is
aa felony
to
avoid
arrest
for aaan
crime
or attempted
attempted
crime
that
is arrest
felony
ofaflight
flight
toor
avoid
attempted
that is aescape
felonyfrom
(or,custody
in jurisdictions
that do In
prosecution
or
and
prosecution crime
or confinement,
confinement,
escape
from
custody
and flight-escape.
flight-escape.
In most
most
not
define crimes
as felonies,
a crime
that is crime
punishable
by
• Calling us TOLL FREE at 1-800-772-1213;
jurisdictions
that to
is punishable
jurisdictions that
that do
do not
not classify
classify crimes
crimes as
as felonies,
felonies, athis
applies
a crime that
death or imprisonment for a term exceeding 1 year).
by
death or imprisonment
a term exceeding
oneexceeding
year (regardless
of the
is punishable
by death or for
imprisonment
for a term
one year
• If you are deaf or hearing impaired, calling us TOLL FREE at
actual
sentence
imposed).
(regardless
of
the
actual
sentence
imposed).
You have an unsatisfied warrant for a violation of probation or
TTY 1-800-325-0778; or
You have
an unsatisfied
for more than 30 continuous days for a
parole
under
Federal or warrant
State law.
violation of probation or parole under Federal or State law.
Calling, visiting or writing your local Social Security office at the
visiting or writing your local Social Security office.
• Calling,
phone number and address shown on your claim receipt.
For general information about Social Security, visit our web site at
www.socialsecurity.gov.
Form SSA-16-BK (12-2010) EF(12-2010)

Page 7

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine if you or a dependent are
eligible for insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, if you fail to provide all or part
of the requested information it may prevent us from making an accurate and timely decision
concerning your or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than determining benefit
payments for you or a dependent. However, we may use it for the administration and integrity of
our 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 an agency to assist us in establishing right to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and 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. (e.g., to the Bureau of Census and to private
entities under contract with us).
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 incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of
Records Notices entitled, Earnings Recording and Self Employment Income System (60-0059)
and Claims Folders Systems (60-0089). Additional information regarding these and other
systems of records notices, are available on-line at www.socialsecurity.gov or at your local
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 20 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 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to our time
estimate to this address, not the completed form.