Information Collection

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

IC 179349 under ICR 202101-0960-004 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-16 Privacy Act Statement (revised).doc	Other-Revised Privacy Act Statement
SSA-16 Privacy Act Statement (revised).doc	Other-Revised Privacy Act Statement
SSA-16 Application for Disability Insurance Benefits SSA-16 (revised).pdf	Form and Instruction
SSA-16 Application for Disability Insurance Benefits SSA-16 (revised).pdf	Form and Instruction
Current SSA-16.pdf Current SSA-16-BK	IC Document
Current SSA-16.pdf Current SSA-16-BK	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-16	Application for Disability Insurance Benefits	SSA-16 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40,346

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40,346	40,346
Annual IC Time Burden (Hours)	13,449	13,449
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-16-BK	Current SSA-16.pdf	08/02/2017

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