Form Ssa 3820 Bk PDF Details

The SSA-3820-BK form, officially titled "Disability Report - Child," serves as a crucial document for those seeking to obtain disability benefits for children under the Social Security Administration (SSA). This comprehensive form allows the SSA to gather necessary information to make an informed decision regarding a child's disability claim. Applicants are advised to read all instructions carefully before filling out the form and to complete as much of it as possible to facilitate the decision-making process. The form underscores the importance of providing detailed medical, educational, and personal data about the child, emphasizing that no question should be left unanswered. If individuals are unsure about any detail, they are encouraged to indicate as such, rather than leaving a blank response. Additionally, it is made clear that the responsibility of obtaining detailed medical records does not fall on the healthcare providers but rather on the applicant, with the SSA willing to assist in this process. Importantly, the form also highlights the significance of adhering to privacy laws and the Paperwork Reduction Act, ensuring applicants that their information is collected and used with the utmost care and only when absolutely necessary. By submitting this form, applicants play a pivotal role in delivering a clear, comprehensive picture of the child's condition and their need for support, directly impacting the outcome of their disability claim.

QuestionAnswer
Form NameForm Ssa 3820 Bk
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namesSSA 3820 BK form ssa 3820 bk

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DISABILITY REPORT - CHILD - Form SSA-3820-BK

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, complete as much of it as you can, and your interviewer will help you finish it.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can.

�Fill out this form before your interview appointment.

�Print or type.

�DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is "none" or "does not apply," write: "don't know," or " none," or "does not apply."

�IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HOSPITAL/CLINIC IN EACH SPACE.

�Each address should include a ZIP code. Each telephone number should include an area code.

�DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However, you can get help from a friend or family member.

�If your appointment is for an interview by telephone, have the form ready to discuss with us when we call you.

�If your appointment is for an interview in our office, bring the completed form with you or mail ahead of time, if you were told to do so.

�Be sure to explain an answer if the question asks for an explanation or if you want to give additional information.

�If you need more space to answer any questions or want to tell us more about an answer, please use the "REMARKS" section on Pages 10 and 11, and show the number of the question being answered.

ABOUT THE CHILD'S MEDICAL AND OTHER RECORDS

If you have any of the following records for the child at home, send them to our office with your completed forms or bring them with you to the interview. If you need the records back, tell us and we will photocopy them and return them to you.

�The child's medical records

�Copies of the child's prescriptions

�The child's Individualized Education Program

�The child's Individualized Family Service Plan

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for you. The information we ask for on this form tells us from whom to request medical and other records. If you cannot remember the names and addresses of any of the doctors or hospitals, or the dates of treatment, perhaps you can get this information from the telephone book, or from medical bills, prescriptions and prescription bottles.

Disability Report - Child - Form SSA-3820-BK

The Privacy and Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is needed by Social Security to make a decision on the named claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the requested information could prevent an accurate or timely decision on the named claimant's claim. Although the information you furnish is almost never used for any purpose other than making a determination about the claimant's disability, such information may be disclosed by the Social Security Administration as follows: (1) to enable a third party or agency to assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal Laws requiring the release of information from Social Security records (e.g., to the General Accounting Office and the Department of Veterans Affairs); and (3) to facilitate statistical research and such activities necessary to assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 1 hour to read the instructions, gather the necessary facts, and answer the questions.

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

SOCIAL SECURITY ADMINISTRATION

Form Approved OMB No. 0960-0577

DISABILITY REPORT - CHILD

SECTION 1 -- INFORMATION ABOUT THE CHILD

A. CHILD'S NAME (First, Middle Initial, Last)

B. CHILD'S SOCIAL SECURITY NUMBER

C. YOUR NAME (If agency, provide name of agency and contact person)

YOUR MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)

CITY

STATE

ZIP CODE

 

 

 

D. YOUR DAYTIME PHONE NUMBER (If you have no phone number, give us a daytime number where we can leave a message for you)

Your Number

Message Number

None

Area Code

Number

 

 

E. What is your relationship to the child?

F. Can you speak English? YES NO

If "NO", what languages can you speak?

If you cannot speak English, is there someone we may contact who speaks English and will give you messages?

NAME

 

RELATIONSHIP TO CHILD

 

 

 

ADDRESS

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

Disability Report - Child - Form SSA-3820-

City

State

Can you read English?

YES

G. Does the child live with you?

YES

 

DAYTIME

 

 

 

 

PHONE

 

 

 

ZIP

Area Code

 

Number

 

 

 

NO

 

 

 

NO If "NO", with whom does the child live?

BK

NAME

 

 

 

 

RELATIONSHIP TO CHILD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

 

 

 

DAYTIME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

City

State

ZIP

 

 

Area Code

Number

 

 

 

 

 

Can this person speak English?

 

YES

NO

 

 

 

 

 

 

If "NO", what languages can this person speak?

Can this person read English?

YES

NO

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 1

SECTION 1 - INFORMATION ABOUT THE CHILD

H. Can the child speak English?

YES

If "NO," what languages can the child speak?

 

I.What is the child's height (without shoes)? What is the child's weight (without shoes)?

NO

J. Does the child have a medical assistance card? (for example Medicaid, Medi-Cal)

YES

If "YES", show the number here:

NO

SECTION 2 - CONTACT INFORMATION

A. Does the child have a legal guardian or custodian other than you?

YES (Enter name, address, phone number, relationship)

NAME

ADDRESS

NO

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

CityState ZIP

DAYTIME PHONE NUMBER

Area Code

Number

RELATIONSHIP TO CHILD

B. Is there another adult who helps care for the child and can help us get information about the child if necessary?

YES (Enter name, address, phone number, relationship)

NAME OF CONTACT

ADDRESS

NO

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

CityState ZIP

DAYTIME PHONE NUMBER

Area Code

Number

RELATIONSHIP TO CHILD

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 2

SECTION 3 - THE CHILD'S ILLNESSES, INJURIES OR

CONDITIONS AND HOW THEY AFFECT HIM/HER

A. What are the child's disabling illnesses, injuries, or conditions?

B. How do the child's illnesses, injuries, or conditions limit his/her daily activities?

C. When did the child become disabled?

Month

 

Day

Year

 

 

 

 

 

 

 

 

 

D. Do the child's illnesses, injuries or conditions cause pain

 

YES

or other symptoms?

 

 

 

 

NO

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 3

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

A.Has the child been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions?

YES

NO

B.Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems?

YES

NO

Tell us who may have medical records or other

information about the child's illnesses, injuries or conditions.

C.List each DOCTOR/HMO/THERAPIST/OTHER. Include the child's next appointment.

1.

NAME

 

 

DATES

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

FIRST VISIT

 

 

 

 

 

 

CITY

STATE ZIP

LAST SEEN

 

 

 

 

 

 

PHONE

 

CHART/HMO # (If known)

NEXT APPOINTMENT

 

 

 

 

 

 

 

Area Code

Number

 

 

REASONS FOR VISITS

 

 

 

2.

WHAT TREATMENT WAS RECEIVED?

NAME

 

 

 

DATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

FIRST VISIT

 

 

 

 

 

 

 

 

CITY

STATE ZIP

LAST SEEN

 

 

 

 

 

 

 

 

PHONE

 

 

CHART/HMO # (If known)

NEXT APPOINTMENT

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

REASONS FOR VISITS

 

 

 

 

WHAT TREATMENT WAS RECEIVED?

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 4

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

DOCTOR/HMO/THERAPIST/OTHER

3.

NAME

 

 

 

DATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

FIRST VISIT

 

 

 

 

 

 

 

 

 

 

CITY

STATE ZIP

LAST SEEN

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

CHART/HMO # (If known)

NEXT APPOINTMENT

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

 

REASONS FOR VISITS

 

 

 

 

 

 

 

 

 

 

 

 

 

WHAT TREATMENT WAS RECEIVED?

 

 

 

 

 

 

 

 

 

 

If you need more space, use Remarks, Section 10.

D. List each HOSPITAL/CLINIC. Include the child's next appointment.

1.

 

 

HOSPITAL/CLINIC

TYPE OF VISIT

 

 

NAME

 

 

 

INPATIENT STAYS

 

 

 

 

 

 

 

(Stayed at least overnight)

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OUTPATIENT VISITS

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

(Sent home same day)

 

 

 

 

 

 

 

STATE

 

ZIP

 

 

 

 

EMERGENCY ROOM

 

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VISITS

DATES

DATE IN

DATE OUT

 

 

DATE FIRST VISIT DATE LAST VISIT

DATES OF VISITS

AREA CODENUMBER

Next appointment

 

The child's hospital/clinic number

 

 

 

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 5

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

HOSPITAL/CLINIC

2.

 

 

HOSPITAL/CLINIC

TYPE OF VISIT

 

NAME

 

 

 

INPATIENT STAYS

 

 

 

 

 

 

(Stayed at least overnight)

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

OUTPATIENT VISITS

 

CITY

 

 

 

 

 

 

 

(Sent home same day)

 

 

 

 

 

 

 

STATE

 

ZIP

 

 

EMERGENCY ROOM

 

PHONE

 

 

 

 

 

 

 

 

 

 

 

VISITS

DATES

DATE IN

DATE OUT

 

 

 

 

 

 

DATE FIRST VISIT DATE LAST VISIT

DATES OF VISITS

AREA CODENUMBER

Next appointment

 

The child's hospital/clinic number

 

 

 

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

If you need more space, use Remarks, Section 10.

E. Does anyone else have medical records or information about the child's illnesses, injuries or conditions (Workers' Compensation, insurance companies, counselors, detention centers, attorneys, and/or tutors), or is the child scheduled to see anyone else?

 

YES

(If "YES," complete information below.)

NO

 

 

 

 

 

 

 

 

NAME

 

 

 

 

DATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

FIRST VISIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST SEEN

CITY

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

NEXT APPOINTMENT

 

 

 

 

 

 

Area Code

 

Number

 

 

 

CLAIM NUMBER (If any)

REASONS FOR VISITS

If you need more space, use Remarks, Section 10.

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 6

SECTION 5 - MEDICATIONS

Does the child currently take any medications for illnesses, injuries or conditions?

If "YES", tell us the following: (Look at the child's medicine bottles, if necessary.)

YES NO

NAME OF MEDICINE

PRESCRIBED BY (Name of Doctor)

REASON FOR

MEDICINE

SIDE EFFECTS THE CHILD HAS

If you need more space, use Remarks, Section 10.

SECTION 6 - TESTS

Has the child had, or will he/she have, any medical tests for illnesses, injuries or

conditions?

YES

NO If "YES", tell us the following (give approximate dates, if necessary).

KIND OF TEST

EKG (HEART TEST)

TREADMILL (EXERCISE TEST)

CARDIAC CATHETERIZATION

BIOPSY--Name of body part

SPEECH/LANGUAGE

HEARING TEST

VISION TEST

IQ TESTING

EEG (BRAIN WAVE TEST)

HIV TEST

BLOOD TEST (NOT HIV)

BREATHING TEST

X-RAY--Name of body part

MRI/CAT SCAN - Name of body part

WHEN DONE, OR WHEN IT WILL BE DONE

(Month, day, year)

WHERE DONE

(Name of Facility)

WHO SENT THE

CHILD FOR

THIS TEST

If the child has had other tests, list them in Remarks, Section 10.

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 7

SECTION 7 - ADDITIONAL INFORMATION

A. Has the child been tested or examined by any of the following?

Headstart (Title V)

Public or Community Health Department Child Welfare or Social Service Agency Women, Infant and Children (WIC) Program Program for Children with Special Health

Care Needs

Mental Health/Mental Retardation Center Vocational Rehabilitation

If "NO", and over age 15, do you want to be referred to Vocational Rehabilitation?

YES YES YES YES

YES YES YES

YES

NO NO NO NO

NO NO NO

NO

B. Is the child participating in the Ticket Program or other program of vocational rehabilitation services, employment services or other support services to help him or her go to work?

YESNO

If you answered "YES" to any of the above in A. or B., please complete C. below:

C. 1. NAME OF AGENCY

ADDRESS

 

 

 

 

 

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

 

 

 

 

 

 

TYPE OF TEST

 

 

WHEN DONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF TEST

 

 

WHEN DONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FILE OR RECORD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. NAME OF AGENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

ZIP

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

 

 

 

 

 

 

TYPE OF TEST

 

 

WHEN DONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF TEST

 

 

WHEN DONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FILE OR RECORD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If there are any other agencies, show them in Remarks, Section 10.

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 8

SECTION 8 - EDUCATION

A. What is the child's current grade in school or the highest grade completed?

B. Is the child currently attending school (other than summer school)?

If "NO", explain why the child is not attending school.

YES

NO

C. List the name of the school the child is currently attending and give dates attended. If the child is no longer in school, list the name of the last school attended and give dates attended.

NAME OF SCHOOL

ADDRESS

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

 

City

 

 

County

State

ZIP

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

DATES ATTENDED

TEACHER'S NAME

Has the child been tested for behavioral or learning problems?

YES

If "YES", complete the following:

 

NO

TYPE OF TEST

TYPE OF TEST

Is the child in special education?

YES

If "YES", and different from above, give:

 

NAME OF SPECIAL EDUCATION TEACHER

WHEN DONE

WHEN DONE

NO

Is the child in speech therapy?

YES

If "YES", and different from above, give:

 

NAME OF SPEECH THERAPIST

 

NO

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 9

SECTION 8 - EDUCATION

D. List the names of all other schools attended in the last 12 months and give dates attended.

NAME OF SCHOOL

ADDRESS

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

City

 

County

State

ZIP

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

DATES ATTENDED

TEACHER'S NAME

Was the child tested for behavioral or learning problems?

YES

If "YES", complete the following:

 

NO

TYPE OF TEST

TYPE OF TEST

Was the child in special education?

YES

If "YES", and different from above, give:

 

NAME OF SPECIAL EDUCATION TEACHER

WHEN DONE

WHEN DONE

NO

Was the child in speech therapy?

YES

If "YES", and different from above, give:

 

NAME OF SPEECH THERAPIST

 

NO

If there are other schools, show them in Remarks, Section 10.

E. Is the child attending Daycare/Preschool?

If "YES", complete the following:

NAME OF DAYCARE/

PRESCHOOL/CAREGIVER

ADDRESS

YES

NO

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

CityCountyState ZIP

PHONE NUMBER

Area Code

Number

DATES ATTENDED

TEACHER'S/CAREGIVER'S NAME

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 10

SECTION 9 - WORK HISTORY

A. Has the child ever worked (including sheltered work)?

If "YES", complete the following:

DATES WORKED

NAME OF EMPLOYER

ADDRESS

YES

NO

 

 

 

 

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

ZIP

PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

Number

 

 

NAME OF SUPERVISOR

B. List job title, and briefly describe the work and any problems the child may have had doing the job.

SECTION 10 - REMARKS

Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you don't have anything to add), be sure to go to the next page and complete the signature block.

FORM SSA-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 11

SECTION 10 - REMARKS

ANYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL FACT FOR USE IN DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL SECURITY ACT COMMITS A CRIME PUNISHABLE UNDER FEDERAL LAW.

Signature of claimant or person filing on claimant's behalf (parent, guardian)

Date (Month, day, year)

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person making the statement must sign below giving their full addresses.

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-3820-BK (5-2002) Destroy 12/2001 Edition EF (5-2002)

PAGE 12

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1. Complete your Form Ssa 3820 Bk with a number of major fields. Gather all the required information and make sure there is nothing omitted!

Learn how to fill out Form Ssa 3820 Bk portion 1

2. Soon after filling in this section, go to the next step and fill out all required particulars in these blanks - If NO what languages can you speak, NAME, ADDRESS, City, RELATIONSHIP TO CHILD, Number Street Apt No if any PO Box, State, ZIP, Area Code, Number, d F o r m S S A B K, Can you read English, YES, G Does the child live with you, and YES.

RELATIONSHIP TO CHILD, If NO what languages can you speak, and NAME inside Form Ssa 3820 Bk

3. This third section should be rather easy, H Can the child speak English, YES, If NO what languages can the child, What is the childs height without, What is the childs weight without, J Does the child have a medical, If YES show the number here, YES, SECTION CONTACT INFORMATION, A Does the child have a legal, YES Enter name address phone, NAME, and ADDRESS - each one of these fields will have to be filled in here.

How one can fill out Form Ssa 3820 Bk stage 3

It is possible to make errors while filling in the J Does the child have a medical, and so ensure that you look again before you'll finalize the form.

4. This particular part arrives with all of the following empty form fields to complete: Number Street Apt No if any PO Box, City, State, ZIP, DAYTIME PHONE NUMBER, RELATIONSHIP TO CHILD, Area Code, Number, B Is there another adult who helps, about the child if necessary, YES Enter name address phone, NAME OF CONTACT, ADDRESS, and Number Street Apt No if any PO Box.

Step number 4 of filling in Form Ssa 3820 Bk

5. The last step to finish this document is integral. Make certain you fill in the necessary form fields, like City, State, ZIP, DAYTIME PHONE NUMBER, RELATIONSHIP TO CHILD, Area Code, Number, FORM SSABK Destroy Edition EF, and PAGE, before finalizing. Failing to do so might generate an incomplete and possibly invalid form!

City, FORM SSABK Destroy Edition EF, and Area Code in Form Ssa 3820 Bk

Step 3: Just after going through the fields, press "Done" and you're done and dusted! Right after getting afree trial account at FormsPal, it will be possible to download Form Ssa 3820 Bk or email it right away. The document will also be readily accessible in your personal account menu with all your adjustments. FormsPal ensures your information privacy with a secure system that in no way records or shares any sort of personal data provided. Feel safe knowing your documents are kept safe whenever you use our editor!

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