Ssa 16 Bk Form – Fill Out and Use This PDF

The SSA-16-BK form, also known as the Application for Disability Insurance Benefits, is a critical document for individuals seeking to apply for disability benefits under Title II and Part A of Title XVIII of the Social Security Act. This form marks the beginning of the application process for individuals claiming a period of disability and/or insurance benefits for which they are eligible. To get started on securing your benefits, click the button below and take your first step towards submitting your SSA-16 form.

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Ssa 16 Bk Form PDF Details

Navigating the process of applying for disability insurance benefits can often feel overwhelming, especially when faced with the detailed and specific questions found on the SSA-16 (06-2018) UF form. This form, crucial for individuals looking to obtain financial support due to disability, serves as an application for disability insurance benefits under the Social Security Act's Title II and Part A of Title XVIII. It comprehensively collects personal information, work history, and the intricate details of one’s medical condition that has led to their inability to work. Apart from personal identification details like name, Social Security Number, and date of birth, it delves into the applicant's work history, including whether they've worked under a different Social Security number or in industries not covered by Social Security. The form also touches on military service, eligibility for pensions not covered by Social Security, and any public disability benefits the applicant might be simultaneously applying for. It accounts for the applicant's marriage history, potentially eligible children, and the specific nature and impact of their disability. With additional sections dedicated to queries about recent earnings, the possibility of work despite the disability, and the impact of the disability on the applicant's capacity to work, the SSA-16 form stands as a comprehensive document aimed at evaluating eligibility for disability benefits. Its completion and accuracy are fundamental not only for the smooth processing of an application but also for ensuring that applicants receive the support they are eligible for, underlining the critical role this document plays in the lives of those applying for disability insurance benefits.

Question	Answer
Form Name	Ssa 16 Bk Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	ssa disability application, what does form disability, form application disability benefits, ssa 16 download

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	Form SSA-16 (06-2018) UF	Page 1 of 7
	Discontinue prior editions
		OMB No. 0960-0618
	Social Security Administration

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.

(Do not write in this space)

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	Yes	No	Unknown
	age 5?	Yes	No	Unknown
	age 5?

6.	(a) Are you a U.S. citizen?	Yes	No
	(a) Are you a U.S. citizen?	(If "Yes," go to item 7)	(If "No," answer (b))
			(If "No," answer (b))


	(b) Are you an alien lawfully present in the U.S.?	Yes	No
	(b) Are you an alien lawfully present in the U.S.?		(If "No," go to item 7)
		(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
	(b) Have you used any other names?	(If "Yes," answer (c))	(If "No," go to item 8)
		(If "Yes," answer (c))	(If "No," go to item 8)
	(c) Other name(s) used.

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

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

9.When do you believe your condition(s) became severe enough to 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	(If "Yes," answer	(If "No," or "Unknown,"
	under Social Security, Supplemental Security Income, or	(If "Yes," answer	(If "No," or "Unknown,"
	under Social Security, Supplemental Security Income, or	(b) and (c))	go to item 11)
	hospital or medical insurance under Medicare?	(b) and (c))	go to item 11)
	hospital or medical insurance under Medicare?

	(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 (06-2018) UF				Page 2 of 7
11. (a) Were you in the active military or naval service (including			Yes	No
		Reserve or National Guard active duty or active duty for training)	(If "Yes," answer	(If "No," go to
		after September 7, 1939 and before 1968?	(b) and (c))	item 12)

	(b) Enter dates of service		FROM: (Month, Year)	TO: (Month, Year)
	(b) Enter dates of service

	(c) Have you ever been (or will you be) eligible for a monthly
		benefit from a military or civilian Federal agency? (Include	Yes	No
		Veteran's Administration benefits only if you waived military	Yes	No

		retirement pay.)

12. Did you or your spouse (or prior spouse) work in the railroad			Yes	No
	industry for 5 years or more?		Yes	No
	industry for 5 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?	Yes	No
			(If "Yes," answer (b))	(If "No," go to item 14)
			(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			Yes	No
		or annuity (or a lump sum in place of a pension or annuity) based	Yes	No
			(If "Yes," answer	(If "No," go to item 15)
		on your work after 1956 not covered by Social Security?	(If "Yes," answer	(If "No," go to item 15)
		on your work after 1956 not covered by Social Security?	(b) and (c))
			(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
						Yes	No
					(If "Yes," answer (b))		(If "No," go to item 16)
					(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 (or age)				Spouse's Social Security Number
	Clergyman or public official					(If none or unknown, so indicate)
	Clergyman or public official
	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	Date of spouse's death	Spouse's Social Security Number
Clergyman or public official	birth (or age)		(If none or unknown, so indicate)
Other (Explain in Remarks)

Form SSA-16 (06-2018) UF

Page 3 of 7

15.(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
Clergyman or public official	(or age)		(If none or unknown, so indicate)
Other (Explain in Remarks)

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.

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

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

Form SSA-16 (06-2018) UF

Page 4 of 7

19.Complete item 19 even if you were an employee.

	(a) Were you self-employed this year or last year?			Yes	No
	(a) Were you self-employed this year or last year?			(If "Yes," answer (b))	(If "No," go to item 20)
				(If "Yes," answer (b))	(If "No," go to item 20)
	(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

20. (a) How much were your total earnings last year?
	Count both wage and self-employment income.			Amount $
	(If none, write "None.")			Amount $
	(If none, write "None.")


	(b) How much have you earned so far this year?
	(If none, write "None.")			Amount $
				Amount $


21. (a) Are you still unable to work because of your illnesses, injuries,				Yes	No
	or conditions?			(If "Yes," go to item 22)	(If "No," answer (b))

				MONTH, DAY, YEAR
	(b) Enter the date you became able to work.

22. Are your illnesses, injuries, or conditions related to your work in				Yes	No
	any way?			Yes	No
	any way?

23. Are you blind or do you have low vision even with glasses or				Yes	No
	contacts?			Yes	No
	contacts?

24. (a) Have you filed, or do you intend to file, for any other public				Yes	No
	disability benefits (including workers' compensation, Black Lung			(If "Yes," answer (b))	(If "No," to item 25)
	benefits and SSI)?

(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
	Veterans Administration Benefits
	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		Yes	No
	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		Yes	No
	employer, such as sick pay, vacation pay, other special pay? If		Yes	No

	"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		Yes	No
	had no earnings?

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		Yes	No
	your disability? If "Yes," enter the parent's name and address and		Yes	No

	Social 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		Yes	No	Unknown
	retirement or disability benefits or who is deceased? If yes, enter the		Yes	No	Unknown

	name(s) and Social Security number, if known, in "Remarks" (if
	unknown, check "Unknown").

Form SSA-16 (06-2018) UF

Page 5 of 7

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 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 statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.

SIGNATURE OF APPLICANT	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

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

2. Signature of Witness

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

Form SSA-16 (06-2018) UF

Page 6 of 7

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, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision concerning your or a dependent's eligibility to benefit payments.

We will use the information you provide to help us determine your or a dependent's eligibility for benefit payments. We may also share the information for the following purposes, called routine uses:

1.To State audit agencies for auditing State supplementation payments and Medicaid eligibility considerations.

2.To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System and 60-0089, entitled Claims Folders System. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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 21235-6401 . Send only comments relating to our

time estimate to this address, not the completed form.

Form SSA-16 (06-2018) UF

Page 7 of 7

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 - or
been received and will be processed as quickly		someone for you - should report the change. The changes
as possible.		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 glad
In the meantime, if you change your address, or if there		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.

How to Edit Ssa 16 Bk Form Online for Free

By using the online PDF editor by FormsPal, you are able to fill out or change social security disability forms right here. Our tool is continually developing to present the very best user experience attainable, and that is due to our resolve for continual enhancement and listening closely to testimonials. It just takes several easy steps:

Step 1: First, open the pdf editor by pressing the "Get Form Button" in the top section of this page.

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As for the blanks of this particular form, this is what you want to do:

1. It's vital to complete the social security disability forms properly, hence be careful while filling in the parts that contain all of these blank fields:

Stage number 1 in filling out what does form disability

2. Once your current task is complete, take the next step – fill out all of these fields - a Have you used any other Social, Yes, If Yes answer b, If No go to item, b Enter Social Security numbers, When do you believe your, keep you from working even if you, a Have you or has someone on your, application for Social Security, b Enter name of person on whose, Yes, Unknown, If Yes answer b and c, If No or Unknown go to item, and c When were you lawfully admitted with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

what does form disability conclusion process shown (part 2)

3. This third part will be simple - complete all the fields in c Enter Social Security Number of to conclude this part.

Part # 3 of submitting what does form disability

It is possible to make errors when filling in the c Enter Social Security Number of, so ensure that you go through it again before you decide to send it in.

4. The next part requires your involvement in the subsequent parts: Form SSA UF a Were you in the, Yes, Reserve or National Guard active, If Yes answer b and c, Page of, No If No go to item, b Enter dates of service, c Have you ever been or will you, Veterans Administration benefits, FROM Month Year, TO Month Year, Yes, Did you or your spouse or prior, industry for years or more, and a Do you have Social Security. Be sure that you provide all of the requested info to go forward.

Filling out segment 4 of what does form disability

5. To wrap up your document, this particular section involves a couple of additional blank fields. Entering a Have you ever been married, Yes, If Yes answer b, No If No go to item, b Give the following information, When Month day year Where Name of, Marriage performed by, Spouses date of birth or age, Clergyman or public official Other, c Enter information about any, Had a marriage that lasted at, Spouses Social Security Number If, Had a marriage that ended due to, the combined period of marriage, and Spouses name including maiden name should wrap up the process and you'll surely be done in the blink of an eye!

Clergyman or public official Other, Spouses date of birth or age, and Spouses Social Security Number If inside what does form disability

Step 3: Before submitting this document, make certain that all form fields were filled in properly. When you determine that it's fine, press “Done." Join us now and easily get access to social security disability forms, available for download. Every modification you make is conveniently kept , enabling you to change the file later on as required. At FormsPal, we do our utmost to make sure that all of your details are kept private.

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