Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration
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SOCIAL SECURITY ADMINISTRATION
TEL
TOE 120/145
OMB No. 0960-0060
(Do not write in this space)
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.
1.
PRINT your name
FIRST NAME, MIDDLE INITIAL, LAST NAME
2.
Enter your Social Security Number
/
/
3.
Check (X) whether you are
Male
Female
4. If this claim is awarded, do you want a password to use SSA's
Yes
No
Internet/phone service?
Answer question 5 if English is not your preferred language. Otherwise, go to item 6.
5.
Enter the language you prefer to:
speak
write
6.
MONTH, DAY, YEAR
(a) Enter your date of birth
(b) Enter name of 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
Yes
No
Unknown
(d) Was a religious record of your birth made before you were age 5?
7.
Yes
No
(a) Are you a U.S. citizen?
Go to item 8
Go to item (b)
(b) Are you an alien lawfully present in the U.S.?
Yes
No
8.
(a) Enter your name at birth if different from item (1)
(b) Have you used any other names?
Yes
No
Go to (c)
Go to item 9
(c) Other name(s) used.
9. (a) Have you used any other Social Security number(s)?
Yes
No
Go to (b)
Go to item 10
(b) Enter Social Security number(s) used.
/
/
10 . Enter the date you became unable to work because of your illness, injuries,
or conditions.
11 .
(a)
Have you (or has someone on your behalf) ever filed an application for
Yes
No
Unknown
Social Security benefits, a period of disability under Social Security,
(If "Yes," answer
(If "No," or "Unknown,"
Supplemental Security Income, or hospital or medical insurance under
(b) and (c).)
go to item 12.)
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.
Form SSA-16-BK (05-2006)
EF (12-2008)
Page 1
Destroy prior editions
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