Form Approved

SOCIAL SECURITY ADMINISTRATION TEL TOE 120/145 OMB No. 0960-0618

(Do not write in this space)
APPLICATION FOR DISABILITY INSURANCE BENEFITS
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.

1. PRINT your name FIRST NAME, MIDDLE INITIAL, LAST NAME

2. Enter your Social Security Number

3. Check (X) whether you are Female Male

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

4. Enter the language you prefer to: speak write

5. (a) Enter your date of birth

(b) Enter name of city and state or foreign country where you
were born.
(c) Was a public record of your birth made before you were age 5? Yes No Unknown

(d) Was a religious record of your birth made before you were age
Yes No Unknown
5?

6. (a) Are you a U.S. citizen? Yes No

(If "Yes," go to item 7) (If "No," answer (b))

(b) Are you an alien lawfully present in the U.S.? Yes No

(If "Yes," answer (c)) (If "No," go to item 7)

(c) When were you lawfully admitted to the U.S.?

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

(b) Have you used any other names? Yes No

(If "Yes," answer (c)) (If "No," go to item 8)

(c) Other name(s) used.

Yes No
8. (a) Have you used any other Social Security number(s)?
(If "Yes," answer (b)) (If "No" go to item 9)

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

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

9.
keep you from working (even if you have never worked)?
10. (a) Have you (or has someone on your behalf) ever filed an Yes No Unknown
application for Social Security benefits, a period of disability
under Social Security, Supplemental Security Income, or (If "Yes," answer (If "No," or "Unknown,"
hospital or medical insurance under Medicare? (b) and (c)) go to item 11)
(b) Enter name of person on whose Social Security
record you filed the other application.

(c) Enter Social Security Number of person named

in (b). If unknown, check this block. Unknown
Form SSA-16-BK (01-2015) ef (01-2015) Page 1
Destroy prior editions
11. (a) Were you in the active military or naval service (including Reserve Yes No
or National Guard active duty or active duty for training) after (If "Yes," answer (If "No," go to
September 7, 1939 and before 1968? (b) and (c)) item 12)
(b) Enter dates of service FROM: (Month, Year) TO: (Month, Year)

(c) Have you ever been (or will you be) eligible for a monthly benefit
from a military or civilian Federal agency? (Include Veteran's Yes No
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 Yes No
years or more?
13. (a) Do you have Social Security credits (for example, based on work Yes No
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 Yes No
annuity (or a lump sum in place of a pension or annuity) based on
(If "Yes," answer (If "No," go to item 12)
your work after 1956 not covered by Social Security? (b) and (c))
(b) I became entitled, or expect to become entitled, beginning MONTH YEAR

(c) I became eligible, or expect to become eligible, 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? Yes No
(If "Yes," answer (b)) 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))
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

Marriage performed by: Spouse's date of birth Spouse's Social Security Number
Clergyman or public official (or age) (If none or unknown, so indicate)

Other (Explain in Remarks)

(c) Enter information about any other marriage if you:
• 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
• 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.
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: Spouse's date of birth Date of spouse's death Spouse's Social Security Number
(or age) (If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
(d) 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."
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

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

Marriage performed by: Spouse's date of birth Date of spouse's death Spouse's Social Security Number
(or age) (If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
Form SSA-16-BK (01-2015) ef (01-2015) Page 2
 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 Yes No
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.

Work Ended (If still

NAME AND ADDRESS OF EMPLOYER
working show
(If you had more than one employer, please list them Work Began
"Not Ended")
in order beginning with your last (most recent) employer)
MONTH YEAR MONTH YEAR

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

19. May the Social Security Administration or State agency reviewing your case, ask your employers
for information needed to process the claim? Yes No
20. Complete item 20 even if you were an employee.
Yes No
(a) Were you self-employed this year or last year? (If "No," go to item 21)
(If "Yes," answer (b))

(b) Check the year (or In what type of trade/business Were your net earnings from the
years) you were were you self-employed? trade or business $400 or more?
self-employed (For example, storekeeper, farmer, (Check "Yes" or "No")
physician)
This year
Last year Yes No
21. (a) How much were your total earnings last year?
Count both wage and self-employment income.
(If none, write "None.") Amount $
(b) How much have you earned so far this year? (If none, write
"None.") Amount $
Form SSA-16-BK (01-2015) ef (01-2015) Page 3
 22. (a) Are you still unable to work because of your illnesses, injuries, or Yes No
conditions?
(If "Yes," go to item 23) (If "No," answer (b))
(b) Enter the date you became able to work. MONTH, DAY, YEAR

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

any way? Yes No
24. (a) Have you filed, or do you intend to file, for any other public
disability benefits (including workers' compensation, Black Lung Yes No
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 Welfare

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

Disability Benefit Questionnaire)
25. (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 Yes No
illnesses, injuries, or conditions? If "Yes", give the amounts and
explain in "Remarks".
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 Yes No
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? Yes No

27. 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 Yes No
Security number, if known, in "Remarks".

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 Yes No Unknown
Security number, if known, in "Remarks" (if unknown, check "Unknown").

Form SSA-16-BK (01-2015) ef (01-2015) Page 4

 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.
Date (Month, Day, Year)
SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink) Telephone Number(s) at which you
may be contacted during the day.
(Include the area code)

DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)

Routing Transit Number Account Number Checking Enroll in Direct Express
Savings 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 2. Signature of Witness

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

Form SSA-16-BK (01-2015) ef (01-2015) Page 5

 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 6

 RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS
Person to Contact About Your Claim SSA OFFICE Date Claim Received

Telephone Number (Include Area Code)

Your application for Social Security disability benefits has is some other change that may affect your claim, you —
been received and will be processed as quickly or someone for you — should report the change. The
as possible. changes to be reported are listed below.

You should hear from us within days after you Always give us your claim number when writing or
have given us all the information we requested. Some telephoning about your claim.
claims may take longer if additional information is needed.
If you have any questions about your claim, we will be
In the meantime, if you change your address, or if there 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. crime that is a felony of flight to avoid prosecution or
To avoid delay in receipt of checks you should ALSO file a confinement, escape from custody and flight-escape. In
regular change of address notice with your post office. most jurisdictions that do not classify crimes as felonies,
this applies to a crime that is punishable by death or
• Your citizenship or immigration status changes. imprisonment for a term exceeding one year (regardless
of the actual sentence imposed).
• You go outside the U.S.A. for 30 consecutive days or
longer. • You have an unsatisfied warrant for more than 30
continuous days for a violation of probation or parole
• Any beneficiary dies or becomes unable to under Federal or State law.
handle benefits.
• Change of Marital Status — Marriage, divorce, annulment
• Custody Change — Report if a person for whom you are of marriage.
filing or who is in your care dies, leaves your care or
custody, or changes address. • If you become the parent of a child (including an adopted
child) after you have filed your claim, let us know about
• You are confined to a jail, prison, penal institution or the child so we can decide if the child is eligible for
correctional facility for more than 30 continuous days for benefits. Failure to report the existence of these children
conviction of a crime, or you are confined for more than may result in the loss of possible benefits to
30 continuous days to a public institution by a court order the child(ren).
in connection with a crime.
• You return to work (as an employee or self-employed)
• You become entitled to a pension, an annuity, or a lump regardless of amount of earnings.
sum payment based on your employment not covered by
Social Security, or if such pension or annuity stops. • Your condition improves.
• Your stepchild is entitled to benefits on your record and • You are under age 65 and you apply for or begin to
you and the stepchild's parent divorce. Stepchild benefits receive workers' compensation (including black lung
are not payable beginning with the month after the month benefits) or another public disability benefit, or the
the divorce becomes final. amount of your present workers' compensation or public
disability benefit changes or stops, or you receive a
• You have an unsatisfied warrant for more than 30 lump-sum settlement.
continuous days for your arrest for a crime or attempted

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.

Form SSA-16-BK (01-2015) ef (01-2015) Page 7