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
S
SSAH01
{Conditional
Notice #1}
Retirement, Survivors and Disability Insurance
I
SSAH05
MESH08
________________________
________________________
________________________
SSAH28
Date: __________________
C
SSAH32
_________(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
I
REFC01
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
Retirement, Survivors and Disability Insurance
I
SSAH05
_
MESH08
______________(1c)_______
___(1d)_______(1e)__(1f)__
SSAH28
Date: _________(2)_______
C
SSAH32
_________(4a)_____________
_________(4b)_____________
_________(4c)_____________
__(4d)____(4e)_______(4f)__
SSAH93
Phone Number: ____(1h)______
C
HDR020
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
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:
Read the entire form SSA-827, front and back.
Write your name and Social Security Number in the upper right corner of the form.
Sign the form in the space shown as “INDIVIDUAL authorizing disclosure.”
Enter your address and daytime phone number in the spaces shown for them.
D
AFB049
ate the form in the space shown as “Date Signed.”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.
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
D
AFB054
Text
change
BRRC01
new UTI
Reporting Responsibilities
I
AFB078
New UTI
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
If you want to get in touch with the person who completed your application, the address is: _______________. The telephone number is __________________.
I
REFC01
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
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.
Review all the entries and confirm that the information is correct.
Write your initials next to any corrections that you make.
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.
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.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
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
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
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AFB063
| File Type | application/msword |
| File Title | Conditional Notice #1 |
| Author | Alexis P. Seth |
| Last Modified By | 666429 |
| File Modified | 2009-11-24 |
| File Created | 2009-11-24 |
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