The understanding and management of the SSA-546 form, officially recognized by the Social Security Administration (SSA), play a pivotal role in the lives of individuals seeking to disclose their workers' compensation or public disability benefits within the framework of their Social Security disability insurance benefits. Structured as a questionnaire, this document meticulously gathers pertinent details including the nature of the benefits being received, whether they stem from workers' compensation schemes across various jurisdictions such as state, federal, or specific occupational disease payments, or from a range of public disability benefits encompassing civil service disability or retirement system benefits, to name a few. The comprehensive scope of this form does not merely confine itself to the aggregation of claim-related information; it extends to facilitating a nuanced understanding of how these external disability benefits might influence one's Social Security benefits. Integral to this process is the adherence to the Privacy Act and Paperwork Reduction Act, underscoring the voluntary yet essential nature of providing complete and accurate information to avoid hampering the determination of benefits eligibility. The SSA-546 form further delineates the procedural norms for submitting this information, alongside emphasizing the legal and ethical implications of providing falsified data, thereby ensuring the integrity of the information submitted and safeguarding the rights of the individual within the disability benefits framework.
| Question | Answer |
|---|---|
| Form Name | Form Ssa 546 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form 546 compensation, social security form 546, ssa 546, social security 546 |
Social Security Administration |
Form Approved |
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OMB No. |
WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT QUESTIONNAIRE
NAME OF WORKER
SOCIAL SECURITY NUMBER
Privacy Act Statement
Collection and Use of Personal Information
Section 224 of the Social Security Act, as amended, authorizes us to collect this information. We will use this information to determine the effect of your worker's compensation or other public disability benefit on your Social Security disability insurance benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from making an accurate and timely decision on your benefit eligibility.
We rarely use the information you supply for any purpose other than for determining the effect of other disability benefits on your Social Security benefits. However, we may use it for the administration and integrity of Social Security 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 Social Security in establishing rights to Social Security benefits and/or coverage;
2To comply with Federal laws requiring the release of information from Social Security 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 and improvement of 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 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 payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices entitled, Claims Folder Record,
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 12.5 minutes to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you may call Social Security at
1. What type of benefit are you receiving, did you receive or do you expect to receive in connection with your disability?
WORKERS' COMPENSATION:
Workers' Compensation - State (including) occupational disease payments)
Black Lung Benefits
Longshore and Harbor Workers' Compensation
Federal Employees' Compensation (FECA- workers' compensation for Federal employees)
PUBLIC DISABILITY BENEFITS:
Civil Service Disability or Federal Employees' Re- tirement System (FERS) Disability Benefits
State Temporary Disability Payments
Federal, State or Local Government Employee Disability Benefits
Other:
2. For each benefit checked above, enter the claim number, employer, insurance carrier and date of injury/illness.
TYPE OF BENEFIT
CLAIM NUMBER
EMPLOYER
INSURANCE CARRIER
DATE OF INJURY/ILLNESS
3.Indicate the State in which you worked when these benefits began or, if workers' compensation is one of the benefits involved, the State in which the injury occurred.
STATE
4. If you are receiving one of the public disability benefits listed in item 1, were Social Security taxes always paid on your earnings?
Yes
No |
(If "No," explain. For example, you were a federal, State or local government employee whose earnings |
were not covered or were not always covered by Social Security.) |
5.Indicate the status of your claim for workers' compensation or other public disability benefits. If you are receiving more than one type of benefit, indicate the status of each claim.
a. |
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Filed for Benefits, or Intend to File but not yet |
d. |
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Entitled |
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Currently Receiving Benefits
b.
c.
Filed for Benefits, but Claim was Denied |
e. |
Claim Denied; Appeal Pending (if appeal is pend- ing, |
f. |
give date you expect a decision.) |
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Received Payments in the Past but not Presently
Other (e.g.,
If a., b., or c. is checked, go on to Item 11 (signature block). If d., e., or f. is checked, complete the remainder of the form.
6. How are (or were) those disability payments made?
Weekly
Monthly
Every Two Weeks
Other (Explain):
FORM
7.a. List the amount(s) and the period(s) of time for which those disability benefits were made. (if only
TYPE OF BENEFIT
AMOUNT
FROM
TO
b. If those payments have stopped, indicate the reason:
Permanent Rating Pending
c. Do you expect those payments to begin again? |
Yes |
Appeal Pending
Other (Explain in item 10, "Remarks")
No |
IF "YES", WHEN (Date) |
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8. |
Have you ever received or been awarded a |
Yes (If "Yes", |
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"compromise and release" or similar type of settlement)? |
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complete item 9) |
No |
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9. |
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a. Date(s) settlement(s) or award(s) made |
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b. Gross Amount(s) |
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$ |
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c. The lump sum represents: |
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per week for |
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weeks beginning |
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d. The amount shown in 9.b. (Gross amount) includes:
(1) MEDICAL EXPENSES OF |
(2) ATTORNEY FEES OF |
(3) RELATED EXPENSES OF |
$ |
$ |
$ |
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10. Remarks: |
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IMPORTANT INFORMATION. PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW
I agree to report if I apply for or begin to receive a workers' compensation (including black lung benefits) or a public disability benefit or the amount that I am receiving changes or stops, or I receive a
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 may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT |
DATE |
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SIGNATURE (First Name, Middle Initial, Last Name) (Write in Ink) |
TELEPHONE NUMBERS(S) at which |
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SIGN |
you may be contacted during the day |
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HERE u |
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MAILING ADDRESS (Number Street, Apt. No., P.O. Box., Rural Route) |
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CITY AND STATE |
ZIP CODE |
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Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the person requesting reconsideration must sign below, giving their full addresses.
(1) SIGNATURE OF WITNESS |
(2) SIGNATURE OF WITNESS |
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ADDRESS (Number and Street, City, State and ZIP Code) |
ADDRESS (Number and Street, City, State and ZIP Code) |
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FORM