Information Collection

Paper Form SSA-16 (Application for Disability Insurance Benefits )

IC 179349 under ICR 201506-0960-007 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-16 Application for Disability Insurance Benefits Paper Form SSA-16 (Application for Disability Insurance Benefits )	Form and Instruction
Form SSA-16 Application for Disability Insurance Benefits Paper Form SSA-16 (Application for Disability Insurance Benefits )	Form
SSA-16-INST - Revised Version - 11-27-13.pdf	Instruction
SSA-16 Application for Disability Insurance Benefits SSA-16-BK - Revised Version - 11-27-13.pdf	Form and Instruction
SSA-16 Application for Disability Insurance Benefits ssa16 - fillable version.pdf	Form
SSA-16-BK - Current Version.pdf Current SSA-16-BK	IC Document
SSA-16-INST - Current Version.pdf Current SSA-16-INST	IC Document

IC Title:

Paper Form SSA-16 (Application for Disability Insurance Benefits )

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.601-.603 20 CFR 404.1501-.1512 20 CFR 404.330-.333 20 CFR 404.310-.311

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-16	No		Paper Only
Instruction		No		Paper Only
Form	SSA-16	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	53,300	53,300
Annual IC Time Burden (Hours)	17,767	17,767
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-16-BK		08/06/2013
Current SSA-16-INST		08/06/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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