Fillable Printable Application for Disability Insurance Benefits

Application for Disability Insurance Benefits

Enter the language you prefer to:

Answer question 4 if English is not your preferred language. Otherwise, go to item 5.

(a) Are you a U.S. citizen?

(b) Enter name of person on whose Social Security

record you filed the other application.

(b) Have you used any other names?

(a) Have you used any other Social Security number(s)?

(b) Enter Social Security number(s) used.

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SOCIAL SECURITY ADMINISTRATION

Form SSA-16-BK (01-2015) ef (01-2015)

Destroy prior editions

APPLICATION FOR DISABILITY INSURANCE BENEFITS

Form Approved

OMB No. 0960-0618

Page 1

TEL TOE 120/145

I apply for a period of disability and/or all insurance benefits for which I am

eligible under Title II and Part A of Title XVIII of the Social Security

Act, as presently amended.

(Do not write in this space)

2. Enter your Social Security Number

3. Check (X) whether you are

5. (a) Enter your date of birth

(b) Enter name of city and state or foreign country where you

were born.

(d) Was a religious record of your birth made before you were age

(If "No," answer (b))

(b) Are you an alien lawfully present in the U.S.?

(If "No," go to item 7)

(If "No," go to item 8)

(a) Have you (or has someone on your behalf) ever filed an

application for Social Security benefits, a period of disability

under Social Security, Supplemental Security Income, or

hospital or medical insurance under Medicare?

(If "Yes," answer

(b) and (c))

(If "No," or "Unknown,"

go to item 11)

in (b). If unknown, check this block.

FIRST NAME, MIDDLE INITIAL, LAST NAME

speak write

Yes No Unknown

Unknown No Yes

No Yes

MaleFemale

Unknown

When do you believe your condition(s) became severe enough to

keep you from working (even if you have never worked)?

7. (a) Enter your name at birth if different from item (1)

(If "Yes," go to item 7)

(If "Yes," answer (c))

(If "Yes," answer (b))

(If "No" go to item 9)

(If "Yes," answer (c))

Unknown

(d) Enter information about any marriage if you:

Form SSA-16-BK (01-2015) ef (01-2015)

Where (Name of City and State)

• Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the

combined period of marriage totaled 10 years or more. If none, write "None." Go on to item 15(d) if

you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before

age 22) and you are divorced from the child's other parent who is now deceased and the marriage lasted less than 10 years.

Where (Name of City and State)

(a) Were you in the active military or naval service (including Reserve

or National Guard active duty or active duty for training) after

September 7, 1939 and before 1968?

Page 2

11.

(If "Yes," answer

(b) and (c))

(If "No," go to

item 12)

(b) Enter dates of service

FROM: (Month, Year) TO: (Month, Year)

from a military or civilian Federal agency? (Include Veteran's

Administration benefits only if you waived military retirement pay.)

12.

Did you or your spouse (or prior spouse) work in the railroad industry for 5

years or more?

13.

(a) Do you have Social Security credits (for example, based on work

or residence) under another country's Social Security System?

(If "Yes," answer (b)) (If "No," go to item 14)

(b) List the country(ies):

14.

(a) Are you entitled to, or do you expect to be entitled to, a pension or

annuity (or a lump sum in place of a pension or annuity) based on

your work after 1956 not covered by Social Security?

(If "Yes," answer

(b) and (c))

(b) I became entitled, or expect to become entitled, beginning

MONTH YEAR

I AGREE TO PROMPTLY NOTIFY the Social Security Administration if I become entitled to a pension or

annuity based on my employment not covered by Social Security, or if such pension or annuity stops.

15.

(a) Have you ever been married?

If "No," go to item 16)

(b) Give the following information about your current marriage. If not currently married,

write "None." (If "None," go on to item 15(c))

Marriage performed by:

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth

(or age)

Spouse's Social Security Number

(If none or unknown, so indicate)

• Had a marriage that lasted at least 10 years; or

• Had a marriage that ended due to the death of your spouse, regardless of duration; or

Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

How marriage ended When (Month, day, year) Where (Name of City and State)

Marriage performed by:

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth

(or age)

Date of spouse's death Spouse's Social Security Number

(If none or unknown, so indicate)

• Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22); and

• Were married for less than 10 years to the child's mother or father, who is now deceased; and

• The marriage ended in divorce

If none, write "None."

Date of divorce (Month, day, year) Where (Name of City and State)

Marriage performed by:

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth

(or age)

Date of spouse's death Spouse's Social Security Number

(If none or unknown, so indicate)

No Yes

Yes

No Yes

Spouse's name (including maiden name) When (Month, day, year)

(If "No," go to item 12)

(If "Yes," answer (b))

Form SSA-16-BK (01-2015) ef (01-2015)

(a) How much were your total earnings last year?

Count both wage and self-employment income.

(If none, write "None.")

(If you need more space, use "Remarks".)

Page 3

Use the "REMARKS" space on page 5 for marriage continuation or explanation.

16. If your claim for disability benefits is approved, your children (including adopted children, and stepchildren) or

dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on your earnings record.

List below: FULL NAME OF ALL such children who are now or were in the past 12 months UNMARRIED and:

• UNDER AGE 18

• AGE 18 TO 19 AND ATTENDING ELEMENTARY OR SECONDARY SCHOOL FULL-TIME

• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

17.

(a) Did you have wages or self-employment income covered under

Social Security in all years from 1978 through last year?

(If "Yes," go to item 18)

(If "No," answer (b))

(b) List the years from 1978 through last year in which you did not

have wages or self-employment income covered under

Social Security.

18. Enter below the names and addresses of all the persons, companies, or Government agencies for whom you have

worked this year and last year. IF NONE, WRITE "NONE" BELOW AND GO TO ITEM 19.

NAME AND ADDRESS OF EMPLOYER

(If you had more than one employer, please list them

in order beginning with your last (most recent) employer)

Work Began

MONTH YEAR MONTH YEAR

19. May the Social Security Administration or State agency reviewing your case, ask your employers

for information needed to process the claim?

20.

Complete item 20 even if you were an employee.

(a) Were you self-employed this year or last year?

(If "Yes," answer (b))

(If "No," go to item 21)

(b) Check the year (or

years) you were

self-employed

In what type of trade/business

were you self-employed?

(For example, storekeeper, farmer,

physician)

Were your net earnings from the

trade or business $400 or more?

(Check "Yes" or "No")

This year

Last year

21.

(b) How much have you earned so far this year? (If none, write

"None.")

Amount $

No Yes

Work Ended (If still

working show

"Not Ended")

No Yes

Amount $

Form SSA-16-BK (01-2015) ef (01-2015)

Do you have a dependent parent who was receiving at least one-half

support from you when you became unable to work because of your

disability? If "Yes," enter the parent's name and address and Social

Security number, if known, in "Remarks".

(a) Did you receive any money from an employer(s) on or after the

date in item 9 when you became unable to work because of your

illnesses, injuries, or conditions? If "Yes", give the amounts and

explain in "Remarks".

Page 4

22.

(a) Are you still unable to work because of your illnesses, injuries, or

conditions?

(If "Yes," go to item 23) (If "No," answer (b))

MONTH, DAY, YEAR

23.

Are your illnesses, injuries, or conditions related to your work in

any way?

24. (a) Have you filed, or do you intend to file, for any other public

disability benefits (including workers' compensation, Black Lung

benefits and SSI)?

(If "Yes," answer (b))

(If "No," to item 25)

(b) The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply):

Veterans Administration Benefits

Supplemental Security Income

Welfare

Other

(If "Other," complete a Workers' Compensation/Public

Disability Benefit Questionnaire)

25.

Amount $

(b) Do you expect to receive any additional money from an employer,

such as sick pay, vacation pay, other special pay? If "Yes," please

give amounts and explain in "Remarks".

Amount $

26. Do you, or did you, have a child under age 3 (your own or your spouse's)

living with you in one or more calendar years when you had no earnings?

27.

28. If you were unable to work before age 22 because of an illness, injury or

condition, do you have a parent (including adoptive or stepparent) or

grandparent who is receiving social security retirement or disability

benefits or who is deceased? If yes, enter the name(s) and Social

Security number, if known, in "Remarks" (if unknown, check "Unknown").

Yes No

No Yes

(b) Enter the date you became able to work.

Yes No

Unknown

Telephone Number(s) at which you

may be contacted during the day.

(Include the area code)

Account Number

Page 5

REMARKS (You may use this space for any explanation. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on the form and any accompanying

statements or forms, and it is true and correct to the best of my knowledge.

SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink)

Date (Month, Day, Year)

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing Transit Number

Checking

Savings

Enroll in Direct Express

Direct Deposit Refused

Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if

different.)

City and State ZIP Code

County (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two

witnesses to the signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's

name in Signature block.

1. Signature of Witness

Address (Number and street, City, State and ZIP Code)

2. Signature of Witness

Address (Number and street, City, State and ZIP Code)

Form SSA-16-BK (01-2015) ef (01-2015)

Page 6

FOR YOUR INFORMATION

An agency in your State that works with us in administering the Social Security disability program is

responsible for making the disability decision on your claim. In some cases, it is necessary for them to get

additional information about your condition or to arrange for you to have a medical examination at

Government expense.

Privacy Act Statement

Collection and Use of Information

Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this information. We will

use the information you provide to determine if you or a dependent are eligible for insurance coverage and/or

monthly benefits.

The information you furnish on this form is voluntary. However, if you fail to provide all or part of the requested

information it may prevent us from making an accurate and timely decision concerning your or a dependent's

entitlement to benefit payments.

We rarely use the information you supply for any purpose other than determining benefit payments for you or a

dependent. However, we may use it for the administration and integrity of our programs. We may also disclose

information to another person or to another agency in accordance with approved routine uses, which include but are

not limited to the following:

1. To enable a third party or an agency to assist us in establishing right to Social Security benefits

and/or coverage;

2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government

Accountability Office and Department of Veterans Affairs);

3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State,

and local level; and

4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social

Security programs. (e.g., to the Bureau of Census and to private entities under contract with us).

We may also use the information you provide in computer matching programs. Matching programs compare our

records with records kept by other Federal, State, or local government agencies. Information from these matching

programs can be used to establish or verify a person's eligibility for federally-funded or administered benefit

programs and for repayment of incorrect payments or delinquent debts under these programs.

A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices

entitled, Earnings Recording and Self Employment Income System (60-0059) and Claims Folders Systems

(60-0089). Additional information regarding these and other systems of records notices, are available on-line at

www.socialsecurity.gov or at your local Social Security office.

Paperwork Reduction Act Statement

- This information collection meets the requirements of 44 U.S.C. § 3507, as

amended by section 2 of the Paperwork Reduction Act of 1995 . You do not need to answer these questions

unless we display a valid Office of Management and Budget control number. We estimate that it will take about 20

minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED

FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through

SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your

telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send

comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001 . Send only

comments relating to our time estimate to this address, not the completed form.

Form SSA-16-BK (01-2015) ef (01-2015)

Page 7

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS

Person to Contact About Your Claim

Telephone Number (Include Area Code)

SSA OFFICE

Date Claim Received

Your application for Social Security disability benefits has

been received and will be processed as quickly

as possible.

You should hear from us within days after you

have given us all the information we requested. Some

claims may take longer if additional information is needed.

In the meantime, if you change your address, or if there

is some other change that may affect your claim, you —

or someone for you — should report the change. The

changes to be reported are listed below.

Always give us your claim number when writing or

telephoning about your claim.

If you have any questions about your claim, we will be

glad to help you.

CLAIMANT SOCIAL SECURITY CLAIM NUMBER

CHANGES TO BE REPORTED AND HOW TO REPORT

FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID

•

You change your mailing address for checks or residence.

To avoid delay in receipt of checks you should ALSO file a

regular change of address notice with your post office.

•

Your citizenship or immigration status changes.

•

You go outside the U.S.A. for 30 consecutive days or

longer.

•

Any beneficiary dies or becomes unable to

handle benefits.

•

Custody Change — Report if a person for whom you are

filing or who is in your care dies, leaves your care or

custody, or changes address.

•

You are confined to a jail, prison, penal institution or

correctional facility for more than 30 continuous days for

conviction of a crime, or you are confined for more than

30 continuous days to a public institution by a court order

in connection with a crime.

•

You become entitled to a pension, an annuity, or a lump

sum payment based on your employment not covered by

Social Security, or if such pension or annuity stops.

•

Your stepchild is entitled to benefits on your record and

you and the stepchild's parent divorce. Stepchild benefits

are not payable beginning with the month after the month

the divorce becomes final.

•

You have an unsatisfied warrant for more than 30

continuous days for your arrest for a crime or attempted

crime that is a felony of flight to avoid prosecution or

confinement, escape from custody and flight-escape. In

most jurisdictions that do not classify crimes as felonies,

this applies to a crime that is punishable by death or

imprisonment for a term exceeding one year (regardless

of the actual sentence imposed).

•

You have an unsatisfied warrant for more than 30

continuous days for a violation of probation or parole

under Federal or State law.

•

Change of Marital Status — Marriage, divorce, annulment

of marriage.

•

If you become the parent of a child (including an adopted

child) after you have filed your claim, let us know about

the child so we can decide if the child is eligible for

benefits. Failure to report the existence of these children

may result in the loss of possible benefits to

the child(ren).

•

You return to work (as an employee or self-employed)

regardless of amount of earnings.

•

Your condition improves.

•

You are under age 65 and you apply for or begin to

receive workers' compensation (including black lung

benefits) or another public disability benefit, or the

amount of your present workers' compensation or public

disability benefit changes or stops, or you receive a

lump-sum settlement.

HOW TO REPORT

You can make your reports online, by telephone, mail, or in person, whichever you prefer. If you are awarded benefits,

and one or more of the above change(s) occur, you should report by:

• Visiting the section "my Social Security" at our web site at www.socialsecurity.gov;

• Calling us TOLL FREE at 1-800-772-1213;

• If you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or

• Calling, visiting or writing your local Social Security office at the phone number and address shown on your claim

receipt.

For general information about Social Security, visit our web site at www.socialsecurity.gov.