Current SSA-1-BK

TEL

Form Approved OMB
No. 0960-0618

TOE 120/145/155

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

u

(b) Check (X) whether you are

u

2. Enter your Social Security number

u

Male

Female

-

-

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:
5.

6.

Write

Speak

Month,

(a) Enter your date of birth

u

(b) Enter name of State or foreign country
where you were born.

u

Day,

(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

Yes

No
(Go to
item (b).)

(a) Are you a U.S. citizen?

u

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

u

No
(Go to
item 7)

Yes

(Go to
item (c))
(c) When were you lawfully admitted to the U.S.?
7.

Year

Enter your full name at birth
if different from item 1(a)

u

FIRST NAME,

MIDDLE INITIAL,

8.

LAST NAME

Yes
u

(a) Have you used any other name(s)?

(b) Other names(s) used.

u

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

u

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

u

Form SSA-1-BK (12-2010) ef (12-2010)
Destroy prior editions

(Go to
item (b).)

No
(Go to
item 9.)

Page 1

Yes

No
(Go to
item 10.)

(Go to
item (b))

-

(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?

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

11.

Yes

u
u

No

MONTH,

YEAR

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

-

(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
u (b) and (c).)

(b) Enter date(s) of service

u

(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?

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

From:

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

Month, Year

Month, Year
To:

Yes

No

Yes

No

u
u

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?

(b) List the country(ies):

No
(If "No," 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.)
u

12.

DAY,

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

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

u
Yes

(c) Are you (or your spouse) filing for foreign Social Security benefits?

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

Yes
u

No

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

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

MONTH

YEAR

MONTH

YEAR

u

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.

Form SSA-1-BK (12-2010) ef (12-2010)

Page 2

16. Have you been married?

16.

u

Yes

No

(If "Yes," answer
item 17.)

(a) Give the following information about your current marriage. If not currently married, write "None"

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

Go on to item 17.

When (Month, day, year)

Where (Name of City and State)

How marriage ended ( If still in
effect, write "Not Ended.")

When (Month, day, year)

Where (Name of City and State)

Marriage performed by:

Spouse's date of birth (or age)

If spouse deceased, give date of death

Spouse's name (including maiden name)

Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)
(b) 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 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.
Use the "Remarks" space to enter the additional marriage information. If none, write "None"
Go on to item 16 (c) if
you have a child(ren) who is under age 16 or disable or handicapped (age 16 or over and disability begain 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.
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:

Spouse's date of birth (or age)

If spouse deceased, give date of death

Spouse's name (including maiden name)

Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)

(c) Enter information about any marriage if you:
• Have a child(ren) who is under age 16 or disable or handicapped (age 16 or over and disability begain 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".
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:

Spouse's date of birth (or age)

If spouse deceased, give date of death

To whom married

Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number ( If none or unknown, so indicate )

Use the 'Remarks' space on page 6 for marriage continuation or explanation.
If your claim for retirement benefits is approved, your children (including adopted children, and
stepchildren) or dependent grandchildren (including step&grandchildren) may be eligible for benefits based
on your earnings record

Form SSA-1-BK (12-2010) ef (12-2010)

Page 3

(Turn to Page 4)

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:

uUNDER AGE 18

uAGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL OR ELEMENTARY
SCHOOL FULL-TIME

uDISABLED 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
(IF THERE ARE NO SUCH CHILDREN, WRITE "NONE" BELOW AND GO ON TO ITEM 19.)

19.

Yes
(If "Yes," go to
item 20.)

(a) Did you have wages or self-employment income covered under Social
Security in all years from 1978 through last year?

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?

u

21. May we ask your employers for wage information needed to process your
claim?

u

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

Yes

No

Yes

No

Yes

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

u

No

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

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

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

This year

Yes

No

Last year

Yes

No

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

u

Amount

(b) 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 ".
Form SSA-1-BK (12-2010) ef (12-2010)

Page 4

$
NONE

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?

u

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 ".

$
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
u

(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, and will accept an age-related reduction.
(b) I am full retirement age (or will be within 12 months), and want benefits beginning with the
earliest possible month providing there is no permanent reduction in my ongoing monthly
benefits.
(c) I want benefits beginning with
.

u
u
u

MEDICARE INFORMATION

If this claim is approved and you are still entitled to benefits at age 65, or you are withing 3 months of age 65 or older you could
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, you will need to contact Social Security to request enrollment.

COMPLETE ITEM 28 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
Medicare Part B (Medical Insurance)- helps cover a doctor's services and outpatient care. It also covers some other services that
Medicare Part A doesn't cover, such as some of the services of physical and occupational therapists and some health care. If you enroll
in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determine when your coverage begins.
In some cases, your premium may be higher based on information about your income we receive from the Internal Revenue Service.
Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you
receive. If you do not receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if
there is any change if the amount of your premium.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about Medicare prescription drug plans and when you
can enroll visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare also can tell you about
agencies in your area that can help you choose your prescription drug coverage.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with Medicare
prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles and prescription co-payments. To learn more
or apply, please visit www..socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the nearest Social Security office.
28. Do you want to enroll in Medicare Part B (Medical insurance)?
29. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for
Supplemental Security Income?
Form SSA-1-BK (12-2010) ef (12-2010)

Page 5

u
u

Yes

No

Yes

No

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

Telephone number(s) at which you may
be contacted during the day

SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)

SIGN
HERE

u

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 (12-2010) ef (12-2010)

Page 6

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 FOF 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.

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

If you have any questions about your claim, we will be
glad to help you.
SOCIAL SECURITY CLAIM NUMBER

CLAIMANT

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 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 right 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

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.
4.

Additional information regarding this form, routine uses of information, and our programs and systems, is available online 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 11 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-1-BK (12-2010) ef (12-2010)

Page 7

CHANGES TO BE REPORTED AND HOW TO REPORT
Failure to report may result in overpayments that must be repaid, and in possible monetary penalties
u 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.)
u Your citizenship or immigration status changes.
u You go outside the U.S.A. for 30 consecutive days or

longer.

u

Any beneficiary dies or becomes unable to handle
benefits.

u

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

$

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.

(Report AT ONCE if this work pattern changes)
u You are confined to jail, prison, penal institution or

u

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).
u You have an unsatisfied warrant for a violation of
probation or parole under Federal or State law.
u

You become entitled to a pension or annuity based on
your employment not covered by Social Security, or if
such pension or annuity stops.
u 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.

u 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.

u Change of Marital Status - Marriage, divorce,

annulment of marriage.

u 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).

HOW TO REPORT

You can make your reports 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:
u

Visiting the section "What You Can Do Online" at
our web site at www.socialsecurity.gov.

u

Calling us TOLL FREE at 1-800-772-1213.

u

If you are deaf or hearing impaired, calling us
TOLL FREE at TTY 1-800-325-0778; or

u Calling, visiting or writing your local Social

Security office.

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.
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 (12-2010) ef (12-2010)

Page 8