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

REPORTING RESPONSIBILITIES FOR DISABILITY INSURANCE BENEFITS
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID

`

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 citizenship or immigration status
changes.

`

Any beneficiary dies or becomes unable to
handle benefits.

`

State law.

`

Change of Marital Status- Marriage, divorce, and
annulment of marriage. You must report marriage
even if you believe that an exception applies.

`

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

`

Your condition improves.

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

`

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
areconfined
confined
jail,
prison,
penal
You are
to atojail,
prison,
penal
institution or
institution
correctional
facility
for conviction
correctional or
facility
for more than
30 continuous
days for
of
a crimeofor
you are
confined
to a public
conviction
a crime,
or you
are confined
for more than 30
institution
by court
orderinstitution
in connection
with
a in
continuous days
to a public
by a court
order
crime.
connection with a crime.

`

You become
to ato
pension,
an annuity,
or a lump sum
You
becomeentitled
entitled
a pension
or annuity
payment
your employment
not covered
based
onbased
youron
employment
not covered
by by Social
Security,Security,
or if such or
pension
or annuity
Social
if such
pensionstops.
or annuity
changes or stops.

`

`

 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.

HOW TO REPORT

You
havean
anunsatisfied
unsatisfied
warrant
for a
violation
of
You have
warrant
for more
than
30 continuous
probation
or parole
under Federal
or under
State Federal
Law. or
days for a violation
of probation
or parole

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.
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 have an unsatisfied warrant for more than 30 continuous days for
your
arrest
for a
or attempted
crime
thatthat
is aisfelony
of flight
to to
for your
arrest
forcrime
a crime
or attempted
crime
a felony
of flight
avoid prosecution or confinement, escape from custody and flightescape. In most jurisdictions that do not classify crimes as felonies, this
a
applies
to aiscrime
that isby
punishable
by death or imprisonment
crime that
punishable
death or imprisonment
for a term for a term
exceeding one year (regardless of the actual sentence imposed).

You can make your reports online, by telephone, mail, or in person, whichever you prefer.
If you are awarded benefits and one or more of the above change(s) occur, you should report by:
Visiting the section
Social
our web
www.socialsecurity.gov
section “my
"What
YouSecurity”
Can Do at
Online"
at site
our at
web
site at www.socialsecurity.gov;
` Visiting
` 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
visiting
writing
local Social
office.
Calling, visiting
or or
writing
your your
local Social
SecuritySecurity
office at the
phone number and address shown on your claim receipt.
` Calling,
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 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.

NOTICE ABOUT DOCUMENTS
We recommend that you keep a copy of all documents you submitted to us.
We are returning the documents you submitted with this claim.

Form SSA-16-INST (11-2010) EF (11-2010)
Destroy prior editions

(OVER)

Collection and Use of Information From Your Application - Privacy Act Notice/Paperwork Reduction 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.
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.

See Revised Privacy Act and PRA Statements Attached
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-INST (11-2010) EF (11-2010)

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Collection and Use of Personal Information
Privacy Act Statement
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 is
eligible to 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, we will be unable to make an accurate and timely decision
concerning your entitlement or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than for determining continuing
eligibility. 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 rights to our benefits
and 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 and improvement of our 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. We use the information from these matching programs 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.