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

Social Security Benefits Application

Documents and Forms

Document Name Document Type
Form SSA-16 Paper Form SSA-16 (Application for Disability Insurance Benefits ) Form and Instruction
SSA-16 Application for Disability Insurance Benefits SSA-16 (revised).docx Form and Instruction
SSA-16 Application for Disability Insurance Benefits SSA-16 (revised).docx Form and Instruction
SSA-16 (current).pdf Current SSA-16-BK IC Document
SSA-16 (current).pdf Current SSA-16-BK IC Document

Information Collection (IC) Details

IC Title:	Paper Form SSA-16 (Application for Disability Insurance Benefits )	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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

Information Collection 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).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29,485	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	29,485	29,485
Annual IC Time Burden (Hours)	24,571	24,571
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-16-BK	SSA-16 (current).pdf	08/08/2022

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