Ssa 4290 F4 Form PDF Details

Are you getting ready to retire from Social Security? If so, you may be aware that the SSA 4290 F4 Form is a critical part of your application package. This form establishes your eligibility for Social Security retirement benefits, and it's important that you understand how to fill it out accurately in order to ensure the most positive outcome possible. In this blog post, we'll provide an in-depth look at the SSA 4290 F4 Form - what it is, why you need it and how to properly complete it - so that you can gain a better understanding of this crucial document before submitting your application. Let's get started!

QuestionAnswer
Form NameSsa 4290 F4 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesOMB, ssa 4290, Page1, 01r

Form Preview Example

 

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMBNo. 0960-0282

DEVELOPMENT OF PARTICIPATION IN A

VOCATIONAL REHABILITATION OR SIMILAR PROGRAM

Part I -To be completed by the State DDS or SSA Field Office

Section A -Beneficiary Information

1. Beneficiary's

Name

(Last, First, MI)

2. Beneficiary's

Date

3. Type of claim

 

 

 

of Birth

 

 

 

 

 

 

r 01r 551 r Concurrent

4. Beneficiary's

Social

Security Number

5. Wage

Earner's

Social Security Number

 

 

 

(if different

from Beneficiary's)

6.Beneficiary's address (Number & Street, City, State, Zip Code)

7.Beneficiary reports that he/she is receiving vocational rehabilitation services, employment services, or other support services from (check one):

An Employment Network under an Individual Work Plan (IWP)

A State Vocational Rehabilitation agency under an Individualized Plan for

Employment (IPE)

Other provider of services under an individualized, written employment plan similar to an IPE

An educational institution under an Individualized Education Program (IEP) to beneficiary age 18 through 21 years

8.Name, address and telephone number of a contact person in the organization/agency identified above:

Section B -DDS/FO Information

9. Signature of Person Who Completed Part I:

 

 

 

 

 

10. Title:

 

11.

Date:

 

 

 

 

12. DDS

or Fa Code:

13.

Telephone

number

(

)

-

 

 

(include area

code):

 

 

 

Form SSA-4290-F4(05-2005)

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