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)

How to Edit Ssa 16 Bk Form Online for Free

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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

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