Form SSA-455 at a glance
What it is: Form SSA-455 (07-2023) is the Disability Update Report of the Social Security Administration.
A filled-in Form SSA-455 example: a worker reports a recent job
How to fill out Form SSA-455, box by box
Name and Address, Claim Number
Enter the Name and Address and the Claim Number.
Within the last 2 years, worked for someone or been self-employed
1. Within the last 2 years have you worked for someone or been self-employed? Check Yes or No.
If yes, complete the information: Work Began (month/year), Work Ended (month/year) and Monthly Earnings.
Your health within the last 2 years: Better, Same or Worse
2. Check the block which best describes your health within the last 2 years: Better, Same or Worse.
Return to work, training program(s) and rehabilitation
3. Within the last 2 years has your doctor told you that you can return to work? Check No or Yes.
4. Within the last 2 years have you attended any school or work training program(s)? Check No or Yes.
5. Would you be interested in receiving rehabilitation or other services that could help you get back to work? Check No or Yes.
Hospitalized or had any surgery
6. Within the last 2 years have you been hospitalized or had any surgery? Check No or Yes. If yes, list the Reason and the Date (month/year).
Gone to a doctor or clinic for your condition
7. Within the last 2 years have you gone to a doctor or clinic for your condition? Check No or Yes. If yes, show the Date and the Reason for the visit.
Telephone Number and Date Report Completed
Enter the Telephone Number and the Date Report Completed (MM/DD/YYYY).
More rules for Form SSA-455
The estimate is 15 minutes to read the instructions, gather the facts, and answer the questions.
Furnishing the information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.
Common questions about Form SSA-455
What is a SSA-455 form?
Form SSA-455 (07-2023) is the Disability Update Report of the Social Security Administration. The Social Security Administration will use the information you provide to further document your claim and permit a determination about continuing disability.
Sources
[1] Form SSA-455 (07-2023), Disability Update Report, Social Security Administration (the Official source link on this page).
