Request for Workers' Compensation/Public Disability Benefit Information

OMB 0960-0098

OMB 0960-0098

SSA uses Form SSA-1709 to verify Worker's Compensation/Public Disability Benefits (WC/PDB). SSA uses the information to compute the correct reduction of disability insurance benefits. The claimants may be able to furnish adequate verification of the WC/PDB benefits by submitting a copy of their award notice, benefit check, etc. SSA considers the claimants the primary sources of verification; therefore, if they provide the necessary evidence, we do not use the form. If the claimants cannot provide evidence, the other reliable source of this information is the entity giving the benefits, its agent (such as an insurance carrier), or an administering public agency. The respondents are Federal, State, and local agencies, insurance carriers and public or private self-insured companies administering WC/PDB.

The latest form for Request for Workers' Compensation/Public Disability Benefit Information expires 2021-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material
All Historical Document Collections
Revision of a currently approved collection 2021-09-03
Approved without change
Revision of a currently approved collection 2018-06-25
Approved without change
Revision of a currently approved collection 2015-05-13
Approved without change
Revision of a currently approved collection 2012-07-19
Approved without change
Revision of a currently approved collection 2009-06-11
Approved without change
Extension without change of a currently approved collection 2006-06-02
Approved without change
Extension without change of a currently approved collection 2003-09-08
Approved without change
Extension without change of a currently approved collection 2002-06-03
Approved without change
Extension without change of a currently approved collection 1999-04-08
Approved without change
Revision of a currently approved collection 1996-02-15
Approved with change
No material or nonsubstantive change to a currently approved collection 1993-03-26
Approved without change
Reinstatement with change of a previously approved collection 1993-01-06
Approved without change
Extension without change of a currently approved collection 1989-10-16
Approved without change
Revision of a currently approved collection 1986-11-26
Approved without change
Revision of a currently approved collection 1984-01-24
Approved without change
Revision of a currently approved collection 1982-07-30
Approved without change
Revision of a currently approved collection 1981-03-27
Approved with change
No material or nonsubstantive change to a currently approved collection 1979-03-28
Approved without change
Reinstatement with change of a previously approved collection 1976-07-29
Approved without change
Extension without change of a currently approved collection 1976-07-09

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