iClaim Applicant After 3rd Party Completion

Social Security Benefits Application

New Notices to Beneficiaries for 3rd-party iClaim Completion

iClaim Applicant After 3rd Party Completion

OMB: 0960-0618

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S

SSAH01

{Conditional Notice #1}


ocial Security Administration

Retirement, Survivors and Disability Insurance

I

SSAH05

mportant Information

MESH08


________________________

________________________

________________________

SSAH28


Date: __________________

C

SSAH32

laim Number: _________

_________(3a)_____________

_________(3b)_____________

_________(3c)_____________

__(3d)____(3e)_______(3f)__


SSAH93



Telephone: ___(1h)____


AFB032

New conditional fill-ins; name changed to upper case casename changed to


An Internet application for Medicare insurance/Social Security benefits was

started/completed for you by _______________ on ____________. ________________________________________________________________________.

CAP005


What Happens Next

AFB044

Name changed to upper case and text change


Once _________________ finishes entering all required information, we will mail you a printed copy of the completed application to review and sign. After you review the application and make sure it is correct, you must sign and return it to the office address shown above. We will not take any action until we receive your signed application.


Once we receive your application, we will decide if you can get benefits. The sooner we receive it, the sooner we can decide.


We may use _________, as the official date of this application. In order to use _________, we must receive the signed application by _______. You may lose Social Security benefits if we do not receive the signed application by ________.

AFB066

Change in conditions


Supplemental Security Income or SSI is a federal program that provides monthly payments to people who have limited income and assets and who are age 65 or older, or blind, or have a disability. For more information about the SSI program, please read the pamphlet, “Supplemental Security Income.”

AFB067

Change in conditions



If you intend to apply for SSI, you need to file your application with us by __ (1) __ or you may lose SSI benefits. Call us at 1-800-772-1213 (TTY 1-800-325-0778) to arrange an appointment to file for SSI. You cannot apply for SSI over the Internet.


CAP003


Additional Information


I

AFB042

Address changed to uppercase

f you want to get in touch with the person who started your Internet application, the address is:
___________________________________. The telephone number is ________________________.




I

REFC01

f You Have Any Questions

REF116


If you have any questions, call, write, or visit any Social Security office and have this letter with you. The telephone number and mailing address of your local

office are shown at the top of this letter.



You can also reach us at 1-800-772-1213 (TTY 1-800-325-0778). We can answer most questions over the phone. The office is located at:


AFBH01


______________(10b)_______

______________(10c)_______

___(10d)____(10e)___(10f)__





{Insert choice of UTI SSAS30 – SSAS39 (Signature Authority: Regional Commissioner’s printed name and designation) based on applicant’s zip code.}










ENC008

New enclosure for Notice1



Enclosure(s):

Pub 05-11069




S

{Comprehensive Notice #2}

SSAH01

ocial Security Administration

Retirement, Survivors and Disability Insurance

I

SSAH05

mportant Information

_

MESH08

_____________(1b)_______

______________(1c)_______

___(1d)_______(1e)__(1f)__


SSAH28


Date: _________(2)_______

C

SSAH32

laim Number: __(13)____

_________(4a)_____________

_________(4b)_____________

_________(4c)_____________

__(4d)____(4e)_______(4f)__



SSAH93


Phone Number: ____(1h)______

C

HDR020

onfirmation Number: __(3)___


AFB032

New fill-in


An Internet application for Social Security benefits/Medicare insurance was started/completed for you by _______________ on ____________. ________________

______________________________________________________________________.

AFB038


If you do not want these benefits, you do not need to contact us. We will not take any action unless we receive your signed application.

RCOC02


What You Need to Do

AFB047


  • Review all the entries on the application and confirm that the information is correct.

  • Correct any information that is wrong and write your initials next to it.

  • Sign and date the application in the space shown as, “Your Signature.”

N

AFB048

OTE: It is important that you sign the application, not the person who filled it in for you or anyone else.

  • G

    AFB049

    Text changes ;

    RIB/DIB only

    ather the documents shown on the enclosed
    List of Acceptable Evidence Documents. We will return all documents and photocopies to you unless you tell us you don’t want them.

  • If you decide to continue applying for disability, complete the form SSA-827 (Authorization to Disclose Information to the Social Security Administration) as shown below:

    1. Read the entire form SSA-827, front and back.

    2. Write your name and Social Security Number in the upper right corner of the form.

    3. Sign the form in the space shown as “INDIVIDUAL authorizing disclosure.”

    4. Enter your address and daytime phone number in the spaces shown for them.

    5. D

      AFB049

      ate the form in the space shown as “Date Signed.”

    6. Do not fill in the large empty box in the middle of the form, put a check in the empty block under “PURPOSE,” or complete any other sections of the form.

    7. Have a witness sign and provide his or her address or phone number in the space shown on the form. If you sign with an “X,” have a second witness sign and provide his or her address.

AFB050

Text changes


  • Mail or bring the signed application, any proofs requested on the List of Acceptable Evidence (C1) and the signed Medical Release form (SSA-827). (C2) If you mail them, please follow the mailing instructions on the final page of this notice and add your return address and correct postage to the envelope provided. If the office location is different than the mailing address, it is listed in “If You Have Any Questions.”


  • I

    AFB051 text change;RIB/DIB only

    f you do not want to apply for disability, you do not need to return the SSA-827 with your retirement application.

CAP005


What Happens Next

AFB052


Once we receive your signed application, we will decide if you can get benefits. The sooner we receive it, the sooner we can decide.


We may use ______ as the official date of this application. In order to use ______, we must receive the signed application by _____. You may lose Social Security benefits if we do not receive the signed application by ______________.

AFB066


Supplemental Security Income or SSI is a federal program that provides monthly payments to people who have limited income and assets and who are age 65 or older, or blind, or have a disability. For more information about the SSI program, please read the pamphlet, Supplemental Security Income.

AFB065

Text and fill-in changes


If you intend to file for SSI, you need to file your application with us by _________

or you may lose SSI benefits. Call us at 1-800-772-1213 (TTY 1-800-325-0778) to arrange an appointment to file for SSI. You cannot apply for SSI over

the Internet.

CAP006


Confirmation Number


Y

AFB053

Text and fill-in change

ou can check the status of your application on the Internet. Please wait at least 5 business days from the date you mail or bring your signed application to us before you check your application status.
Just go to the “Social Security Online” home page at www.socialsecurity.gov, select "Check the Status of Your Application”, then enter the Confirmation Number shown at the top of this notice. Please guard this number carefully. It's the key to your application information. Social Security employees will never ask for your Confirmation Number.


D

AFB054

Text change

isability claims take longer to process than other types of Social Security claims
because of the need to obtain sufficient medical evidence to show that you are disabled. It may take 90-120 days before "Check the Status of Your Application" will reflect a final decision on your disability claim.

BRRC01 new UTI


Reporting Responsibilities


I

AFB078

New UTI

t is important that you let us know as soon as possible whenever one of the changes listed below occurs. You need to contact us if:

  • you change your mailing address;

  • your citizenship or immigration status changes; or

  • your Medicare Part B premium is automatically paid from an account at a bank or other financial institution, and you change institutions or close the account.

You can call, write, visit our office or our website at http://www.socialsecurity.gov/pgm/reach.htm to make a report. You should have your Social Security number handy when you contact us.

Information you give to another government agency may be provided to Social Security by the other agency, but you must also report any changes to us.


A

AFB042

Address in uppercase

CAP003

dditional Information


If you want to get in touch with the person who completed your application, the address is: _______________. The telephone number is __________________.


I

REFC01

f You Have Any Questions

REF116


If you have any questions, call, write, or visit any Social Security office and have this letter with you. The telephone number and mailing address of the office processing your claim are shown at the top of this letter. You can also reach us at 1-800-772-1213 (TTY 1-800-325-0778). We can answer most questions over the phone. The office location is: (C3)

AFBH01


______________(10b)_______

______________(10c)_______

___(10d)____(10e)___(10f)__





{Insert choice of UTI SSAS30 – SSAS39 (Signature Authority: Regional Commissioner’s printed name and designation) based on applicant’s zip code.}







Enclosure(s):

R

ENC008

Two new enclosures

eturn Envelope

Application Summary

Pub 05-11069

List of Acceptable Evidence Documents

Medical Release (SSA-827)



AFB055



List of Acceptable Evidence Documents


You need to send us the documents shown below. Send all documents you have with your signed application. We will help you get the other documents. You should not delay sending your application if you don’t have all the documents. You may lose benefits if you delay.


NOTE: Include your Social Security number when you mail documents to us. We need this to match the documents to your application. Please write your Social Security number on a separate sheet of paper and include it in the envelope with your documents. Do not write anything on your original documents. You may bring the documents to any Social Security office if you don’t want to mail them. They will be examined and returned to you.


CAUTION: Don’t mail foreign birth records or any Department of Homeland Security (DHS) documents to us – especially those you are required to keep with you at all times. These documents are extremely difficult, time-consuming, and expensive to replace if lost. Some cannot be replaced. Instead, bring them to any Social Security office where they will be examined and returned to you.

CAP007


Proof of Age

AGE012


You must submit a birth certificate or religious record of birth made before you were age 5 if one was established. This is our preferred proof of age.


You need to provide at least two other documents to prove your age if a public or religious record was not made prior to age 5. Examples of other documents include a delayed birth certificate, school records, a State census record, vaccination record, insurance policy, hospital admission record, etc. Please provide us with two of the oldest of these documents.


We must see the original document(s). We cannot accept photocopies unless they are certified by the office that issued the original. We will return any document you show us.

CAP008


Proof of Citizenship or Naturalization

CZN067


We can accept most documents that show that you were born in the United States. We need to see a document such as a U.S. consular report of birth, a U.S. passport, a Certificate of Naturalization, or a Certificate of Citizenship if you are a U.S. citizen born outside the U.S. We need to see your INS Form 1-551 (Green Card) to verify your 9-digit Alien Registration Number (A-Number) if you are not a U.S. citizen. We need to see your INS Form I-94 to verify your Admission Number if you have an 11-digit Admission Number, even if you have an A-Number.


We must see the original documents, but we cannot accept them if they have expired. We cannot accept photocopies.

MSV007


Proof of U.S. Military Service Before 1968


Your benefit amount may increase if you have any period of active duty in the U.S. military prior to 1968. We need proof of your active duty service to determine this. Military service credits for active duty are automatically posted after 1967. Proof of U.S. military service includes your military service papers (e.g., Form DD-214-Certification of Release or Discharge from Active Duty). We need to see all DD-214s with beginning and ending dates of active duty prior to 1968. We can accept uncertified photocopies of your military service.

MSV007

WAG031


Proof of Wages from Your Employer


We need to see Form W-2 for wages you received last year. We can accept pay stubs or statements for the current year as long as Social Security earnings (also known as FICA or OASDI earnings) are displayed separately. We can accept uncertified photocopies of your W-2 forms.

SEI004


Proof of Self-Employment Income


We need to see a copy of Schedule C and SE from your tax return for last year. We can accept uncertified photocopies of your self-employment tax returns.

MER013


Medical Evidence


We will ask for your medical documents if you have received treatment for your alleged disability. This includes copies or photocopies of medical records, doctors’ reports, and recent test results. Your treatment records are used along with other information to see if you meet our definition of disability.


We need information about your medical treatment for any illnesses, injuries, or conditions that limit your ability to work. We will not need to request copies of medical documents from your doctors, hospitals, clinics, or other medical sources if you already have them. We can process your application faster with this information. Do not delay filing your application if you do not have these documents. We will ask the medical sources you list to send them to us. We may ask you to go to a special examination at our expense if you have not received treatment, or we do not obtain enough documents about your condition(s).


We also ask for information such as:

  • What are your illnesses, injuries, or conditions?

  • When did they begin?

  • How do they limit your activities?

  • What did medical test show?

  • What treatment did you receive?


In addition, we ask for information about your ability to do work-related activities, such as walking, sitting, lifting, carrying, and understanding and remembering instructions.


We do not ask your doctors to decide if you are disabled.


We can accept uncertified photocopies of your medical documents.

WCP056


Proof of Workers’ Compensation and/or Similar Benefits


You indicated that you received or are receiving a temporary or permanent workers’ compensation-type benefit. We need to see award letters, pay stubs, settlement agreements or other proof you may have.


We will need documents that show:

  • The date of your injury or illness;

  • The amount and effective date of your current payment and all increases or decreases within the last 17 months or, if later, since payments began;

  • The type of payment if you receive workers’ compensation (i.e., temporary partial, temporary total, permanent partial, permanent total, a lump sum, or an annuity);

  • T

    WCP056

    he frequency of your payments (e.g., weekly, bi-weekly, monthly, bi-monthly, etc.) or the period covered by a lump sum;

  • The last day you were entitled to a payment and the last payment amount (if different from your regular payment amount) if benefits have already ended;

  • The name, address, and phone number of your employer;

  • The name, address, and phone number of the insurance carrier if they make the payments instead of your employer.


We can accept uncertified photocopies of your workers’ compensation and/or similar benefit information.

Internet Application Summary

AFB056

New fill-in


Instructions

This form summarizes all the information provided by the person who started an Internet application for Social Security benefits/Medicare insurance on your behalf.


  1. Review all the entries and confirm that the information is correct.

  2. Write your initials next to any corrections that you make.

  3. Sign and date the application in the space shown as, “Your Signature.”


NOTE: It is important that you sign the application, not the person who filled it in for you or anyone else.

  1. M

    AFB057 numbering format change

    Text change

    ail or bring the signed application to the office address shown on the notice mailed with this summary. If you mail it, add your return address and the correct postage to the envelope provided.

  2. If the office location is different than the mailing address, it is listed under “If You Have Any Questions” at the end of the notice.

AFB058

New fill-in



Top of Form

I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age, Survivors, and Disability Insurance) and Part A and Part B of Title XVIII (Health Insurance for the Aged and Disabled) of the Social Security Act, as presently amended.


(Summary below applies to RIB/DIB application only)

Preparer’s Information

Preparer’s name: Doug Binder

Preparer’s organization: Binder & Binder, LLC

Preparer’s relationship to applicant: Attorney

Preparer’s address: 123 Old Court Rd., Baltimore, MD 21208

Preparer’s phone number: (410) 224-9444


Applicant Identification

Applicant name: Erika Davies

Social Security Number: XXX-XX-9999

Gender: Female

Date of Birth: October 18, 1950


Contact Information

Mailing Address

Mailing Address: 3601 Clark’s Lane, Baltimore, MD 21215

Reside at this address: No

Residence Address: 2415 St. Paul Street, Baltimore, MD 21218


Phone and email

Daytime telephone number: 443-765-4008

Type of phone: Other

Best time to call: 2

Email address: [email protected]


Preferred language for speaking: English

Preferred language for reading: English


Birth and Citizenship Information

Born in the United States or a U.S. territory or commonwealth: Yes

City of birth: Baltimore

State of birth: MD

U.S. citizen: Yes

Type of citizenship: U.S. Citizen born inside the U.S.


Confirmation Number

The confirmation number is: 12345678


Other Social Security Numbers

Any other Social Security Numbers used: Yes

Other SSN 1: 444-99-4444

Other SSN 2:

Other SSN 3:

Other SSN 4:

Other SSN 5:


Other Names

Any other names used: Yes

Other name 1: Erika Seth

Other name 2:

Other name 3:

Other name 4:

Other name 5:


Marriage Information

Currently married: Yes

Spouse's Name: Edward Davies

Spouse's Social Security Number: 909-99-9999

Spouse's age: 62

Marriage Date: April 19, 1988

Marriage Type: Married by Clergy or Public Official

Married in U.S. or a U.S. territory or commonwealth: Yes

City, town or county:

U.S. state, territory or commonwealth:


Prior Marriages

First prior spouse’s name: Eric Smith

First prior spouse’s Social Security Number: UNKNOWN

First prior spouse’s date of birth: December 15, 1952

First prior marriage began on: April 28, 1971

First prior marriage type: Clergy or Public Official

First prior marriage began in: Bath, England

First prior marriage ended on: October 4, 1974

First prior marriage ended in: Bath England

First prior marriage ended because of: Death


Second prior spouse’s name: John Doe

Second prior spouse’s Social Security Number: UNKNOWN

Second prior spouse’s date of birth: December 15, 1952

Second prior marriage began on: April 28, 1971

Second prior marriage type: Clergy or Public Official

Second prior marriage began in: Bath, England

Second prior marriage ended on: October 4, 1974

Second prior marriage ended in: Bath England

Second prior marriage ended because of: Death


Third prior spouse’s name: Peter Piper

Third prior spouse’s Social Security Number: UNKNOWN

Third prior spouse’s date of birth: December 15, 1952

Third prior marriage began on: April 28, 1971

Third prior marriage type: Clergy or Public Official

Third prior marriage began in: Bath, England

Third prior marriage ended on: October 4, 1974

Third prior marriage ended in: Bath England

Third prior marriage ended because of: Death


Fourth prior spouse’s name: Grant Tomb

Fourth prior spouse’s Social Security Number: UNKNOWN

Fourth prior spouse’s date of birth: December 15, 1952

Fourth prior marriage began on: April 28, 1971

Fourth prior marriage type: Clergy or Public Official

Fourth prior marriage began in: Bath, England

Fourth prior marriage ended on: October 4, 1974

Fourth prior marriage ended in: Bath England

Fourth prior marriage ended because of: Death


I have NO additional prior marriages.


Children

Child 1: Ethan Davies

Child 2: Ephraim Davies

Child 3:

Child 4:

Child 5:

Child 6:

Child 7:

Child 8:

Child 9:

Child 10:


I have NO additional children.


Military Details

Military Service prior to 1968: Yes

Receiving or eligible to receive military or civilian Federal agency benefit: Yes

Type of benefit: Military


First Military Period Type of Duty: Reserve

First Military Period Branch of Service: Army

First Military Period Start Date: 02/02/1934

First Military Period End Date: 02/02/1936


Second Military Period Type of Duty: Reserve

Second Military Period Branch of Service: Army

Second Military Period Start Date: 02/02/1934

Second Military Period End Date: 02/02/1936


Third Military Period Type of Duty: Reserve

Third Military Period Branch of Service: Army

Third Military Period Start Date: 02/02/1934

Third Military Period End Date: 02/02/1936


Fourth Military Period Type of Duty: Reserve

Fourth Military Period Branch of Service: Army

Fourth Military Period Start Date: 02/02/1934

Fourth Military Period End Date: 02/02/1936


Fifth Military Period Type of Duty: Reserve

Fifth Military Period Branch of Service: Army

Fifth Military Period Start Date: 02/02/1934

Fifth Military Period End Date: 02/02/1936


Sixth Military Period Type of Duty: Reserve

Sixth Military Period Branch of Service: Army

Sixth Military Period Start Date: 02/02/1934

Sixth Military Period End Date: 02/02/1936


Seventh Military Period Type of Duty: Reserve

Seventh Military Period Branch of Service: Army

Seventh Military Period Start Date: 02/02/1934

Seventh Military Period End Date: 02/02/1936


Eighth Military Period Type of Duty: Reserve

Eighth Military Period Branch of Service: Army

Eighth Military Period Start Date: 02/02/1934

Eighth Military Period End Date: 02/02/1936


Ninth Military Period Type of Duty: Reserve

Ninth Military Period Branch of Service: Army

Ninth Military Period Start Date: 02/02/1934

Ninth Military Period End Date: 02/02/1936


Tenth Military Period Type of Duty: Reserve

Tenth Military Period Branch of Service: Army

Tenth Military Period Start Date: 02/02/1934

Tenth Military Period End Date: 02/02/1936


I have NO additional Periods of Military Duty.


Employer Details

Worked for an employer in 2007: YES

Worked or will work for an employer in 2008

Will work for an employer in 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Employer’s name: Southwest Airlines

Employer’s address: 1 Plain Dr., Chicago, IL 00747

Date employment began: September 1987

Date employment end: March 2007

Another employer in 2007, 2008, or 2009: YES


Self-employment Details

Self-employed in 2007: YES

Type of business: Law firm

Self-Employment net income greater than $400: YES


Self-employed in 2008: YES

Type of business: Home medical practice

Self-Employment net income greater than $400: YES


Self-employed in 2009: YES

Type of business: Car wash

Self-Employment net income greater than $400: YES


Supplemental Information

Worked outside the US: YES

Eligible for benefits under a foreign social security system: YES

Country: Pakistan

Filed or intend to file under that country’s social security system: YES

Spouse worked outside the US: YES

Spouse eligible for benefits under a foreign social security system: YES

Spouse filed or intends to file under that country’s social security system: YES

Agree with the earning history as shown on Social Security statement: YES

Corporate Officer of employer: YES

Related to a Corporate Officer of employer: YES

Receiving earnings from a Family Corporate or other closely held corporation: YES

Permission granted to contact employer(s) if necessary: YES


Total Earnings

Total of all wages and tips in 2007: $12000

Earned wages, tips, and net earnings from self-employment over $1080 a month or performed substantial services in self-employment in all months of 2007: NO

Months did not earn over $1080: January, March and June

Total of all wages and tips in 2008: $15000

Earned wages, tips, and net earning from self-employment over $1130 a month or performed substantial services in self-employment in all months of 2008: NO

Months did not earn over $1130: January and June

Total of all wages and tips expected in 2009: $22000

Expected wages, tips, and net earnings from self-employment over $1130 a month or from performing substantial services in self-employment in all months of 2009: NO

Months will not earn over $1130: January, March and June


Total earnings include any special payments paid in one year but earned in another: NO


Other Pensions/Annuities

Ever worked in a job where Social Security taxes were not deducted or withheld: YES

Receiving a pension or annuity based on this non-covered work: YES

Pension or annuity based on government employment: YES

Worked on railroad 5 years or more: YES

Receiving or eligible to receive a railroad pension or annuity: YES

Spouse worked for railroad 5 years or more: YES

Spouse receiving eligible to receive railroad pension or annuity: YES

Worked for federal government in 1983: YES

Spouse worked for Federal Government in 1983: YES


Direct Deposit Details

Bank routing number: 001520633

Account number: 009979955285

Account type: Checking

No account: No


Benefit Information

Filed for Supplemental Security Income: NO

Intend to file for Supplemental Security Income: YES

Previous application for Medicare, Social Security Benefits, or Supplemental Security Income (SSI) benefits: YES

Types of Benefits: Medicare, Social Security, Supplemental Security Income

Previous filing on your own Social Security Number: NO

Name and Social Security Number of person(s) on whose record previously applied:

Joe Public 999-99-9999

Bill D. Blocks 990-90-9099

Enrolled in Medicare Part B: NO

Want to enroll in Medicare Part B: NO

Enrolled on own SSN: NO

Receiving Medicaid: NO

Covered under a group health plan: NO

Ability to Work

Limiting illnesses, injuries, or conditions: BROKEN BACK, HIGH BLOOD PRESSURE

Blind: NO

Work-related illnesses, injuries, or conditions: YES

Now able to work: YES

Date became able to work: 09/ 2000


Disability Payments

Filed or intend to file for workers’ compensation or other public disability benefits: NO

Reason for not filing: I RECEIVE ENOUGH ALREADY –

Received money from your employer on or after date became unable to work: YES

Amount of pay received: 11234.50

Type of pay received: SICK, VACATION, OTHER

Expect to receive future payment from employer: YES

Amount of future payment from employer: 13345.90

Type of future payment from employer: SICK, VACATION, OTHER


Dependents

Has parent who receives one-half support from you: YES

First Parent’s Name: John Doe Public

First Parent’s Address: 123 Main Street, Gwynn Oak, MD 21207

Second Parent’s Name: Roberta Lee Public

Second Parent’s Address: 321 South Main Street, Liberty, MD 21044

Number of years without earnings while caring for child under age 3: 6

Years with no earnings: 1998, 1999, 2000, 2001, 2002, 2003, 2004


Authorization

Authorized disclosure of medical information: YES

Receive reduced retirement benefits while waiting for disability decision: YES


(Summary below applies to Medicare only)

Preparer’s Information

Preparer’s name: Doug Bender

Preparer’s organization: Bender & Bender, LLC

Preparer’s relationship to applicant: Attorney

Preparer’s address: 123 Old Court Rd., Baltimore, MD 21208

Preparer’s phone number: (410) 224-9444

Applicant Identification Page

Applicant Name: John Q. Smith

Social Security Number: XXX-XX-XXXX

Gender: Male

Date of Birth: June 12, 1957


Contact Information Page

Mailing Address

Mailing Address: 1234 W. JONES AVENUE APARTMENT 215 TAMPA FL 32222


Reside at this address: Yes

Phone and email

Daytime telephone number: (321) 8111-1234

Type of phone: Other

Best time to call: Noon to 5 p.m.

Email address:

Language preferences

Preferred language for speaking: English

Preferred language for reading: English

Birth and Citizenship Information Page

Born in the United States or a U.S. territory or commonwealth: Yes

City of Birth: Washington

State of Birth: DISTRICT OF COLUMBIA

US Citizen: Yes

Type of Citizenship: US Citizen born inside US


Confirmation Number

The confirmation number is: 12345678

Initial Information Section:

Note: (New page prior to the Application Number page)

Medicare question: Do you wish to file for Medicare Only, excluding all cash benefits: YES

Medicare question: Are you already enrolled in Medicare under a social security number other than your own: NO


Benefit Information Page:

Do you want to enroll in Medicare Part B: YES

Are you receiving Medicaid: YES

Note: The following is based on if the Medicaid question is answered yes

What is your Medicaid (state health insurance) number: 1234567 or I don’t know my Medicaid (state insurance) number.

What state provides you with Medicaid (state health insurance): MD

When did your Medicaid (state health insurance) start: 5/2007


Has your Medicaid (state health insurance) ended: (If “yes” then follow-up question)

When did your state health insurance end: 3/2008

Are you covered under an employer sponsored group health Plan: (If “yes” then follow-up question)

Is this coverage from- Own Employment/Spouse or Other Employment: Own

Employment


Employment Information:

What date did employment start: April 27, 1973

Has employment ended: YES

What date did employment end: March 13,2009

Health Insurance Coverage:

What date did coverage start: June 1973

Has coverage ended: YES


What date did coverage end: March 2009


Remarks Page

Remarks: Claimant has estimated the exact dates of her employment and group health plan coverage

Remarks:



RMK001

RMK002


AFB079

New text for MO


­­­­­I understand I must file a separate application when I wish to establish entitlement

to monthly Social Security benefits.


I

AFB064

declare under penalty of perjury that I have examined all the information on this application and it is true and correct to the best of my knowledge.


AFB060


Signature _______________________________ Date________________________

AFB061


Witnesses are required only if this application has been signed by mark (x) above. If signed by (x), two witnesses to the signing who know the applicant must sign below, giving their full addresses.



_

CA401M

____________________________ _____________________________

Signature of Witness Signature of Witness

_____________________________ _____________________________

Number and Street Address Number and Street Address


_____________________________ _____________________________

City, State, and Zip Code City, State, and Zip Code



This form should be submitted to the address shown on your notice.

AFB062


Privacy Act Statement

The Social Security Administration (SSA) is allowed to collect the facts on this form under Section 205 of the Social Security Act. We need this information to efficiently process your application. Giving us this information is voluntary. However, without them we may not be able to process your application. While the information you furnish on this form would almost never be used for any purpose other than the intended use of this form, such information may be disclosed by SSA as generally permitted under 5 U.S.C. sec. 552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary for administrative purposes or as authorized by routine uses in the applicable Privacy Act system of records. SSA has access to the information you provide on this application and is authorized to keep even information on applications that were partially completed. This is for purposes of helping you complete the application process. Explanations about possible reasons why information you provide us may be used or given out are available upon request from any Social Security office.


Paperwork Reduction Act Statement

P

AFB063

aperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. sec. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to review, confirm or sign this application summary unless we display a valid Office of Management and Budget control number; the control number is 0960-0618. We estimate that it will take about 20 minutes to read the instructions, review the information contained in the summary, and sign the application. 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.


19

84239801

File Typeapplication/msword
File TitleConditional Notice #1
AuthorAlexis P. Seth
Last Modified By666429
File Modified2009-11-24
File Created2009-11-24

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