Fillable Printable Application for Retirement Insurance Benefits
Fillable Printable Application for Retirement Insurance Benefits
Application for Retirement Insurance Benefits
2.
WriteSpeak
1.
(b) Enter Social Security number(s) used.
(a) Have you used any other name(s)?
(b) Check (X) whether you are
Answer question 3 if English is not your language preference. Otherwise, go to item 4.
Enter the language you prefer to:
(a) Enter your date of birth
Enter your Social Security number
FIRST NAME, MIDDLE INITIAL, LAST NAME(a) PRINT your name
Page 1(Over)
Yes
No
(d) Was a religious record of your birth made before you were age 5?
YesNoUnknown
(c) Was a public record of your birth made before you were age 5?
YesNoUnknown
MaleFemale
(b) Enter name of city and state, or foreign country where
you were born.
Enter your full name at birth if different from
item 1(a)
FIRST NAME, MIDDLE INITIAL, LAST NAME
YesNo
8.(a) Have you used any other Social Security number(s)?
6.
Month, Day, Year
NoYes
(a) Are you a U.S. citizen?
(b) Are you an alien lawfully present in U.S.?
(b) Other names(s) used.
(Go to item 7.)(Go to item (b).)
(Go to item (b).)(Go to item 8.)
(Go to item (b))(Go to item 9.)
3.
4.
5.
7.
Form Approved
OMB No. 0960-0618
TELTOE 120/145/155
SOCIAL SECURITY ADMINISTRATION
APPLICATION FOR RETIREMENT INSURANCE BENEFITS
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the
Aged and Disabled) of the Social Security Act, as presently amended.
Supplement. If you have already completed an application entitled
"APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS",
you need complete only the circled items. All other claimants must complete
the entire form.
(Do not write in this space)
(c) When were you lawfully admitted to the U.S.?
YesNo
(Go to item (c))(Go to item 6)
Form SSA-1-BK (02-2014) ef (02-2014)
Destroy prior editions
11.
10.
12.
13.
(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?
Did you or your spouse (or prior spouse) work in the railroad industry
for 5 years or more?
(a) Do you (or your spouse) have Social Security credits (for example
based on work or residence) under another country's Social
Security system?
YesNo
9.
(a) Are you, or during the past 14 months have you been, unable
to work because of illnesses, injuries or conditions?
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) If "Yes", enter the date you became unable to work.
(b) Enter date(s) of service
(c) Are you (or your spouse) filing for foreign Social Security benefits?
YesNo
Yes
No
NoYes
YesNo
NoYes
Page 2
Yes
NoUnknown
NoYes
14.
(If "No," go on
to item 15.)
(If "Yes,"
answer (b)
and (c).)
(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?
(b) I became entitled, or expect to become entitled, beginning
(c) I became eligible, or expect to become eligible, beginning
MONTH, DAY, YEAR
MONTH
MONTH
YEAR
YEAR
(If "No," go
to item 11.)
(If "No," go
to item 12.)
(If "No," go
to item 14.)
(If "Unknown,"
go to item 11.)
(If "Yes,"
answer (b)
and (c).)
(If "Yes," answer
(b) and (c).)
(If "Yes,"
answer (b)
and (c).)
Do not answer question 9 if you are one year past full retirement age or older; go to question 10.
(a) Have you (or has someone on your behalf) ever filed an
application for Social Security, Supplemental Security
Income, or hospital or medical insurance under Medicare?
(c) Enter Social Security number(s) of person named in
(b). (If unknown, so indicate.)
Month, YearMonth, Year
(b) List the country(ies):
From:To:
Answer question 14 only if you were born January 2, 1924, or later. Otherwise go on to question 15.
I agree to promptly notify the Social Security Administration if I become
entitled to a pension, an annuity, or a lump sum payment based on
my employment not covered by Social Security, or if such pension or
annuity stops.
(b) Enter name of person(s) on whose Social Security
record you filed other application.
Form SSA-1-BK (02-2014) ef (02-2014)
(c) Have you ever been (or will you be) eligible for monthly benefits
from a military or civilian Federal agency? (Include Veterans
Administration benefits only if you waived Military retirement pay).
Form SSA-1-BK (02-2014) ef (02-2014)
Page 3
NoYes
15.
(a) Give the following information about your current marriage. If not currently married, write "None"
Go on to item 16(b).
Spouse's Social Security number (If none or unknown, so indicate)
Marriage performed by:
Spouse's name (including maiden name) When (Month, day, year)
When (Month, day, year)Where (Name of City and State)
Spouse's date of birth (or age)If spouse deceased, give date of death
Other (Explain in "Remarks")
Where (Name of City and State)
(b) Enter information about any other marriage if you:
• Had a marriage that lasted at least 10 years; or
• 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.
16.
How marriage ended (If still in effect,
write "Not Ended.")
(If "Yes," answer item 16.)(If "No," go to item 17.)
If your claim for retirement benefits is approved, your children (including adopted children and stepchildren)
or dependent grandchildren (including step grandchildren) may be eligible for benefits based on your
earnings record.
Spouse's name (including maiden name) When (Month, day, year)Where (Name of City and State)
(c) Enter information about any marriage 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
• 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."
Use the 'Remarks' space on page 6 for marriage continuation or explanation.
Have you been married?
Clergyman or public official
• Had a marriage that ended due to death of your spouse, regardless of duration; or
Use the "Remarks" space to enter the additional marriage information. If none, write "None." Go on to item 16 (c) 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.
Spouse's Social Security number (If none or unknown, so indicate)
Marriage performed by:
When (Month, day, year)Where (Name of City and State)
Spouse's date of birth (or age)If spouse deceased, give date of death
Other (Explain in "Remarks")
How marriage ended
Clergyman or public official
To whom married When (Month, day, year)Where (Name of City and State)
Spouse's Social Security number (If none or unknown, so indicate)
Marriage performed by:
When (Month, day, year)Where (Name of City and State)
Spouse's date of birth (or age)If spouse deceased, give date of death
Other (Explain in "Remarks")
How marriage ended
Clergyman or public official
(Turn to Page 4)
Page 4
(a) How much were your total earnings last year?
19.
18.(a) Did you have wages or self-employment income covered under Social
Security in all years from 1978 through last year?
(b) List the years from 1978 through last year in which you did not have
wages or self-employment income covered under Social Security.
Enter below the names and addresses of all the persons, companies, or government agencies for whom you have
worked this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TOITEM 20.
NoYes
This year
MonthYearMonthYear
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
Work Ended (If still
working, show "Not
Ended")
YesNo
20.May we ask your employers for wage information needed to process your claim?
21.
In what kind of trade or business were you
self-employed? (For example, storekeeper, farmer,
physician)
Last year
YesNo
(If "No," go
to item 22.)
NONE
$
22.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
Mar.Apr.
MayJul.Aug.
Sept.Oct.Nov.Dec.
Feb.Jan.
ALL
Amount
Jun.
NoYes
(If you need more space, use "Remarks".)
(If "No," answer
item (b).)
(b) Check the year or
years in which you
were self-employed
(If "Yes," go
to item 19.)
Were your net earnings from
your trade or business $400 or
more? (Check "Yes" or "No")
(b) Place an "X" in each block for EACH MONTH of last year in which you did
not earn more than *$ in wages, and did not perform substantial
services in self-employment. These months are exempt months. If no months
were exempt months, place an "X" in "NONE". If all months were exempt
months, place an "X" in "ALL".
THIS ITEM MUST BE COMPLETED, EVEN IF YOU ARE AN EMPLOYEE.
(a) Were you self-employed this year and/or last year?
17.List below FULL NAME OF ALL your children (including adopted children, and stepchildren) or dependent
grandchildren (including stepgrandchildren) who are now or were in the past 6 months UNMARRIED and:
• UNDER AGE 18
• AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL OR ELEMENTARY
SCHOOL FULL-TIME
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
Form SSA-1-BK (02-2014) ef (02-2014)
(IF THERE ARE NO SUCH CHILDREN, WRITE "NONE" BELOW AND GO ON TO ITEM 18.)
Also list any student who is between the ages of 18 to 23 if such student was both: 1. Previously entitled to Social
Security benefits on any Social Security record for August 1981; and 2. In full-time attendance at a
post-secondary school.
NoYes
(If "Yes,"
answer (b).)
Do you want to enroll in Medicare Part B (Medical insurance)?
If you are within 2 months of age 65 or older, blind or disabled,
do you want to file for Supplemental Security Income?
Page 5
Form SSA-1-BK (02-2014) ef (02-2014)
26.
Answer this item ONLY if you are now in the last 4 months of your taxable year (Sept., Oct., Nov., and Dec., if
your taxable year is a calendar year.
If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15),
enter here the month your fiscal year ends.
(Month)
$
(b) Place an "X" in each block for EACH MONTH of next year in which you do
not expect to earn more than *$ in wages, and do not expect to
perform substantial services in self-employment. These months will be
exempt months. If no months are expected to be exempt months, place an
"X" in "NONE". If all months are expected to be exempt months, place an "X"
in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
NoYes
NoYes
MEDICARE INFORMATION
Amount
(a) How much do you expect your total earnings to be this year?
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
(b) Place an "X" in each block for EACH MONTH of this year in which you did
not or will not earn more than *$ in wages, and did not or will not
perform substantial services in self-employment. These months are exempt
months. If no months are or will be exempt months, place an "X" in "NONE".
If all months are or will be exempt months, place an "X" in "ALL".
23.
$Amount
DO NOT ANSWER ITEM 26 IF YOU ARE FULL RETIREMENT AGE AND 6 MONTHS OR OLDER; GO TO ITEM 27.
24.
25.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8 AND ANSWER ONE OF THE
FOLLOWING ITEMS:
NONE
Mar.Apr.
MayJul.Aug.
Sept.
Oct.
Nov.Dec.
Feb.Jan.
ALL
Jun.
(a) How much do you expect to earn next year?
NONE
Mar.Apr.
MayJul.Aug.
Sept.Oct.Nov.Dec.
Feb.Jan.
ALL
Jun.
(a) I want benefits beginning with the earliest possible month, and will accept an age-related reduction.
(b) I am full retirement age (or will be within 12 months), and want benefits beginning with the earliest possible
month providing there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with .
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you
could automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at
age 65. If you live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B,
and you will need to contact Social Security to request enrollment.
COMPLETE ITEM 27 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
27.
28.
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other
services that Medicare Part A does not cover, such as some of the services of physical and occupational therapists and
some home health care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your
premium will be determined when your coverage begins. In some cases, your premium may be higher based on
information about your income we receive from the Internal Revenue Service. Your premiums will be deducted from any
monthly Social Security, Railroad Retirement, or Office of Personnel Management benefits you receive. If you do not
receive any of these benefits, you will get a letter explaining how to pay your premiums. You will also get a letter if there
is any change in the amount of your premium.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug
plans and when you can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY
1-877-486-2048). Medicare can also tell you about agencies in your area that can help you choose your prescription
drug coverage. The amount of your premium varies based on the prescription drug plan provider. The amount you pay
for Part D coverage may be higher than the listed plan premium, based on information about your income we receive
from the Internal Revenue Service.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you
with Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and
prescription co-payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY
1-800-325-0778) or visit the nearest Social Security office.
1. Signature of Witness
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that
anyone who knowingly gives a false or misleading statement about a material fact in this information, or
causes someone else to do so, commits a crime and may be sent to prison, or face other penalties, or both.
City and State
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the
Signature block.
SIGNATURE OF APPLICANT
Date (Month, day, year)
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks," if different.)
ZIP CodeCounty (if any) in which you now live
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
SIGNATURE (FirstName,MiddleInitial,LastName)(Writeinink.)
Form SSA-1-BK (02-2014) ef (02-2014)
Page 6
Telephone number(s) at which
you may be contacted during
the day
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
Address (Number and Street, City, State and ZIP Code)
Direct Deposit Payment Information (Financial Institution)
Routing Transit NumberAccount Number
Direct Deposit Refused
Enroll in Direct ExpressChecking
Savings
CLAIMANT
SSA OFFICE
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY RETIREMENT INSURANCE BENEFITS
Your application for Social Security 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
TELEPHONE
NUMBER(S) TO CALL
IF YOU HAVE A
QUESTION OR
SOMETHING TO
REPORT
DATE CLAIM RECEIVED
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 on page 8.
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.
SOCIAL SECURITY CLAIM NUMBER
BEFORE YOU RECEIVE A
NOTICE OF AWARD
AFTER YOU RECEIVE A
NOTICE FOF AWARD
Page 7
- This information collection meets the requirements of 44 U.S.C. § 3507, as
amended bysection 2 of the Paperwork Reduction Act of 1995.You do not need to answer these questions unless we
display a valid Office ofManagement and Budget control number. We estimate that it will take about 11 minutes to read
the instructions, gather the facts, andanswer 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 21235-6401. Send onlycommentsrelating to our time
estimate to this address, not the completed form.
Form SSA-1-BK (02-2014) ef (02-2014)
Collection and Use of Information From Your Application—Privacy Act Notice/Paperwork Reduction Act Notice
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
You (are) (are not) earning wages of more
than $ a month.
You (are) (are not) self-employed rendering
substantial services in your trade or business.
CHANGES TO BE REPORTED AND HOW TO REPORT
Failure to report may result in overpayments that must be repaid, and in possible monetary penalties
If you are under full retirement age, retirement benefits cannot be payable to you for any month before the month
in which you file your claim.
If you are over full retirement age, retirement benefits may be payable to you for some months before the month
in which you file this claim.
If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do
not actually receive your full benefit amount for one or more months before full retirement age because benefits
are withheld due to your earnings, your benefit will be increased at full retirement age to give credit for this
withholding. Thus, your benefit amount at full retirement age will be reduced only if you receive one or more full
benefit payments prior to the month you attain full retirement age.
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
withyourpostoffice.)
Any beneficiary dies or becomes unable to handle
benefits.
Work Changes - On your application you told us you
expect total earnings for to be
$ .
(Report AT ONCE if this work pattern changes)
Page 8
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.
For those under full retirement age, the law requires
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable year
in which you earn more than the annual exempt
amount. You may contact SSA to file a report.
Otherwise, SSA will use the earnings reported by
your employer(s) and your self-employment tax
return (if applicable) as the report of earnings
required by law, to adjust benefits under the earnings
test. It is your responsibility to ensure that the
information you give concerning your earnings is
correct. You must furnish additional information as
needed when your benefit adjustment is not correct
based on the earnings on your record.
HOW TO REPORT
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU ANSWER QUESTION 26.
You go outside the U.S.A. for 30 consecutive days or
longer.
Your citizenship or immigration status changes.
(Year)
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 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.
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.
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.
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).
Form SSA-1-BK (02-2014) ef (02-2014)
•
•
•
•
•
•
•
•
•
•
•
•
•
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.
•
•
•
