SSA-455 Disability Update Report

FORM APPROVED
OMB NO. 0960-0511

SOCIAL SECURITY ADMINISTRATION

DISABILITY UPDATE REPORT
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R.
404.1589 and 416.989 authorize us to collect this information. We will use the information you provide to further document your
claim and permit a determination about continuing disability.
The information you furnish on this report is voluntary. However, failure to provide us with the requested information could prevent
us from making an accurate and timely decision on your claim.
We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security benefits. 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,
See Revised Privacy Act Statement Attached
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement 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.
A complete list of routine uses for this information are available in our Systems of Records Notices entitled, Claims Folders Systems
(60-0089) and the Master Beneficiary Record (60-0090). These notices, additional information regarding this form, routine uses of
information, and our programs and systems 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 (OMB) control number. The OMB control number for this collection is 0960-0511. We estimate that it will
take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time
estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Claim Number

Name and Address

1. Within the last 2 years have you worked for someone or been self-employed?
Yes

No

If yes, please complete the information below.
Work Began
(month/year)

Work Ended
(month/year)

Monthly
Earnings

1.

/

/

$

2.

/

/

$

3.

/

/

$

Form SSA-455 (07-2013)

2.

Check the block which best describes your health within the last 2 years:
Better

Same

Worse

3.

Within the last 2 years has your doctor told you that you can return to work?
Yes
No

4.

Within the last 2 years have you attended any school or work training program(s)?
Yes

No

5.

Would you be interested in receiving rehabilitation or other services that could help
you get back to work?
Yes
No

6.

Within the last 2 years have you been hospitalized or had any surgery?
Yes
No
If yes, please list below:
Reason
1.

Date: (month/year)

2.
3.
7.

Within the last 2 years have you gone to a doctor or clinic for your condition?
Yes
No
If yes, show the date and the reason for the visit.
1. Date
Reason
2. Date
Reason
3. Date
Reason

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 a 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 may face other penalties, or
both.
Sign
Here
Form SSA-455 (07-2013)

Date

Telephone Number