Ssa 455 Ocr Sm PDF Details

Ocr Ssa 455 form is used to report wages earned by self-employed individuals. This form must be filed annually with the Social Security Administration. The information on this form is used to determine the amount of social security tax that is owed. The deadline for filing this form is April 15th. Self-employment can be a great way to earn extra income, but it also comes with some added responsibilities. One of these responsibilities is filing a SSA 455 Ocr sm form each year. This form reports the wages earned by self-employed individuals, and it is used to determine how much social security tax they owe. The deadline for filing this form is April 15th.

We have gathered some interesting information regarding the ssa 455 ocr sm. It might be helpful to learn its size, the actual time necessary to fill out the form, the blanks you'll have to fill in, etc.

QuestionAnswer
Form NameSsa 455 Ocr Sm
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesform ssa 455 ocr sm, ssa 455, ssa455, form 455

Form Preview Example

Social Security Administration

Disability Update Report

Information and Completion Instructions

Why We Are

Writing To

You Now

The Social Security Administration must regularly review the cases of people getting disability beneits to make sure they are still disabled

under our rules. It is time for us to review this case. Enclosed is a Disability Update Report for you to answer to update us about

you (or the person for whom you are the representative payee), your health and medical conditions, any recent work activity, or any recent

training.

What To

Please read the following information, and the instructions for

Do First

completing the report form, before you answer the questions.

 

 

 

When to

Please complete the report, sign it and send it to us in the enclosed

Respond

envelope within 30 days. If there is no return envelope with the report,

please send the signed report to us at:

 

 

Social Security Administration

 

P.O. Box 4550

 

Wilkes-Barre, PA 18767-4550

 

 

What We Do

We consider the information you give us together with the information

With Your

in your claim record to decide if we need to do a full medical review.

After we receive the completed report, we will notify you whether or not

Answers

we need to do a full medical review.

 

 

If You Need

It is important that information you give us is accurate. We have tried

Help To

to make report questions easy to understand and answer. But, if you

ind that you do not understand a question or questions, please contact

Answer The

us, your authorized representative, a social service agency, your doctor

 

Report

or clinic, or some other person you trust.

 

 

If You Need

If you need to contact us, please call us toll-free at 1-800-772-1213

To Contact

or TTY for the hearing impaired at 1-800-325-0778. We can answer

most questions over the telephone. If you prefer to visit or call one of

Us

our ofices, please use the 800 number to get the local ofice address

 

and telephone number. Please have the Disability Update Report with

 

you if you call or visit an ofice. It will help us answer your questions.

 

Also, if you plan to visit an ofice, you should call ahead to make an

 

appointment. This will help us serve you.

 

 

We May Need

Sometimes, we may need more information from you. If so, we will try

To Contact

to call you. If you do not have a telephone, please give us a number

where we can leave a message for you. Please print the telephone

 

You

number in the section provided on the back of the report form.

If We Don’t Hear From You

If you do not complete and return the report promptly, or tell us why you cannot respond, we may stop sending payments to you. If it is necessary to stop your payments, we will send you another letter telling you what we plan to do.

FORM SSA-455-OCR-SM (10-2013)

Continued on the Reverse

If We Do A

Full Medical

Review

If we decide to do a full medical review of your case, you can give us any information which you believe shows that you are still disabled,

such as medical reports and letters from your doctors about your health. Then, we look at all your information in your case, including the

new information you give us, and decide whether you continue to be disabled under our rules.

Appeals And

When we review your case, we may ind that you are no longer disabled

Continued

under our rules, and your payments may stop. If your payments stop,

Beneits

you can appeal our decision or you can ask us to continue to make

payments while you appeal.

 

 

 

If You Want

Do you want to work, but worry about losing your payments or

To Work

Medicare before you can support yourself? We want to help you go to

work when you are ready. But, work and earnings may affect your

 

beneits. Your local Social Security ofice can tell you more about work

 

incentives, and how work and earnings can affect your beneits.

The Privacy

And

Paperwork

Reduction

Acts

Collection and Use of Personal Information - Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R. 404.1589 and 416.989 authorize us to collect this information. We will use the information you provide to

further document your claim and permit a determination about continuing disability.

The information you furnish on this report is voluntary. However, failure to provide us with the requested information could prevent us from making an accurate and timely decision on your

claim.

We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security beneits. 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 beneits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Ofice 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.

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 beneit programs and for repayment of payments

or delinquent debts under these programs.

A complete list of routine uses for this information are available in our Systems of Records Notices entitled, Claims Folders Systems (60-0089) and the Master Beneiciary Record (60-0090). These

notices, additional information regarding this form, routine uses of information, and our programs and systems are available online at www.socialsecurity.gov or at your local Social Security ofice.

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 Ofice of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0511. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only

comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD

21235-6401.

FORM SSA-455-OCR-SM (10-2013)

2

GENERAL INSTRUCTIONS

-HOW TO COMPLETE “SCANNABLE” FORMS

The Disability Update Report is a scannable form which can be “read” electronically. To help us process your report, please follow these instructions when you answer the questions on the report form:

1.USE BLACK INK OR A #2 PENCIL.

2.KEEP YOUR NUMBERS, LETTERS, AND “X’S” INSIDE THE BOXES.

3.NUMBERS: Try to make your numbers look like these:

0 1 23456789

4.LETTERS: Print in CAPITALS. Try to make your letters look like these:

AB C DE F G H I J K L M NO P Q R S T U V WX Y Z

5.MONEY AMOUNTS: Show dollars only. Do not use dollar signs

($), and do not show cents. For example, show $1,540.30 like this:

Dollars Only, No Cents

01 , 540

6.DATES: Put a number in each box. For example, show September

9, 2003, like this:

Month Year

0903

7. THE REPORT PERIOD: The “report period” is the period of

 

 

time for which we need information. It is described at the top of

 

 

 

the report form to the right of your name, and again in questions 1

 

 

 

through 6. Usually, the report period is the last 24 months, but it

 

 

 

may be less. It is important that you keep the report period

 

 

 

in mind when answering the questions.

 

 

 

 

 

 

 

HOW TO FILL OUT THE REPORT FORM

 

 

QUESTION 1.a. -

If you have not worked during the report period, place an “X” in the

 

 

Have You

box below “NO”, and go on to question 2. If you have worked, mark the

 

 

Worked?

box below “YES”, and answer question l.b.

 

 

 

 

 

QUESTION 1.b. -

Describe your most recent work activity irst. Print the months

 

 

When You

and years you began and ended working in the boxes under “Work

 

 

Worked And

Began” and “Work Ended.” If you are working now, print the

 

 

current month and year in the irst set of boxes under “Work Ended.”

 

 

Your Monthly

 

 

Print your gross monthly earnings for the periods you worked in the

 

 

Earnings

boxes.

 

 

 

 

 

 

 

 

 

QUESTION 2 -

Place an “X” in the box below “YES” if you have attended school and/or

 

 

School Or Work

a training program during the report period; otherwise, mark the box

 

 

below “NO”. This could include high school equivalency programs,

 

 

Training

 

 

college courses, vocational evaluation or retraining programs, but

 

 

 

 

 

 

generally would not include group therapy or hobbies.

 

FORM SSA-455-OCR-SM (10-2013)

3

Continued on the Reverse

QUESTION 3 -
Can You Work?
QUESTION 4 -
How Is Your Health?
QUESTION 5 -
Treatment By A Doctor Or Clinic
How To Answer Question 5.a.
Question 5.b. - Reason For The Visit
Date of Visit

Tell us if you have discussed with your doctor whether you can return to any kind of work, and if so, whether the doctor told you that you can return to work, even if the work permitted is less physically demanding and/or less stressful than your usual work. Place an “X” in only 1 box.

We want to know how your overall health now compares to what it was

at the beginning of the report period. You may feel that your health has gotten worse, has improved, or you may feel that your health is about the same and has not gotten better or worse. Place an “X” in only 1 box.

A “doctor or clinic” can include treatment such as evaluations, checkups,

counseling, providing prescriptions or medicine by a doctor, visiting nurse, family health center, psychologist, licensed counseling service, physical therapist, a chiropractor or other licensed health provider. Treatment may be provided in person or by telephone or other contact.

If you have not been treated by a doctor or clinic during the report period, place an “X” in the box below “NO”, and go on to question 6. If you have gone to a doctor or clinic during the report period, mark the box below ‘’YES”, and answer question 5.b.

Please start with the most recent visit and then work backwards in time. Print as much information as will it, but keep a space between each word. Try to use the most important or key word(s), such as

ARTHRITIS or BAD BACK, or HYPERTENSION or HIGH BLOOD.

Your medical bills or doctor can provide a short, accurate description.

Print the month and year you were treated. Complete all 4 boxes. For example, print September 10, 2003, as 09 03.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

QUESTION 6.a -

Have You Been

Hospitalized Or

Had Surgery?

Question 6.b. -

Reason For

Treatment

Place an “X” in the box below “NO” if you have not been hospitalized or

not had surgery during the report period. If you have been hospitalized or had surgery during the report period, then place an “X” in the box below ‘’YES” and answer question 6.b.

Please report your most recent treatment irst and then work backwards in time. Try to provide the most important information. Keep a space between each word. Your medical bills or doctor can provide short, accurate words.

Date of Treatment

Print the month and year you were hospitalized or had surgery. Be sure to use all four spaces. If you were hospitalized more than one month, print last month you were hospitalized.

NOTE: If needed, use the “REMARKS” section on side 2 of the form.

Remarks Section

If you need more room to answer questions l.b., 5.b. and/or 6.b., or

there are any other facts or statements you want us to consider, place an “X” in the box and write in this section. If necessary, use an extra

piece of paper.

Signature, Date

and Telephone

Sections

Please sign the report form as you usually sign your name. Please provide a telephone number where you can be reached during the day.

FORM SSA-455-OCR-SM (10-2013)

4

Printed on Recycled Paper

Disability Update*Report

DATE:

Social Security Administration, P.O. Box

, Wilkes-Barre. PA 18767-

FORM APPROVED

OMB NO. 0960-0511

 

 

 

PAYEE’S NAME AND ADDRESS

 

REPORT PERIOD

 

 

 

From:

To The Present

 

 

 

 

 

 

 

 

 

BENEFICIARY

 

PSC:

TELEPHONE NUMBER

CLAIM NUMBER

Please be sure to use black ink or a #2 pencil to print your answers. Also, read the enclosed instructions before completing the form. Finally, remember that when answering the questions, the “REPORT PERIOD” for

which we need information about you is fromto the present. If you have any questions, call 1-800-772-1213 or TTY for the hearing impaired at 1-800-325-0778.

1. a. Since

have you worked for someone

or been self-employed?

YES NO

b. If you answered “YES” to 1.a., please complete the information below.

WORK BEGAN

WORK ENDED

MONTHLY EARNINGS

Month

Year

Month

Year

Dollars Only, No Cents

Most

Recent

Work

1.

2.

3.

$

$

$

,

,

,

2. Have you attended any school or work training program(s)

since?

YES NO

3. Since

to the present...(Please place an ‘X’ in one box only):

 

 

my doctor and I

 

my doctor

 

 

 

 

 

have not discussed

 

told me I

 

 

whether I can work.

 

cannot work.

my doctor told me I can work.

4. Place an “X” in only one box which best describes your health

now as compared to

.

 

 

 

 

BETTER

 

 

SAME

 

 

 

 

WORSE

Form SSA-455-OCR-SM (10-2013)

Continued on the Reverse

FOR SSA USE ONLY

AC?

5. a. Have you gone to a doctor or clinic for treatment

(including evaluations, checkups, counseling,

 

prescriptions, or medicine) since

?

b. If you answered “YES” to 5.a., please list:

 

 

Reason For Visit:

 

Most

 

 

Recent

1.

 

Visit

 

 

 

 

2.

 

 

3.

 

YES NO

Month Year

6. a. Have you been hospitalized or had surgery

since?

b. If you answered “YES” to 6.a., please list:

YES NO

Reason For Hospitalization or Surgery:

Month

Year

Most

Recent

1.

2.

3.

REMARKS: If you use this space to further answer questions 1. through 6., place an “X” in the box to the right and print on the lines below.

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.

SIGN HERE

TODAY’S DATE

 

 

TELEPHONE NUMBER (include Area Code)

Form SSA-455-OCR-SM (10-2013)

 

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