Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 2
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7Answer item 12, if you have been in the military service. Otherwise, go to item 13.
12.
(a)
Were you in the active military or naval service (including Reserve or
Yes
No
National Guard active duty or active duty for training) after September
(If "Yes," answer
(If "No," go to
7, 1939 and before 1968?
(b) and (c).)
item 13.)
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
Yes
No
a military or civilian Federal agency? (Include Veterans Administration
benefits only if you waived military retirement pay.)
13.
Have you or your spouse worked in the railroad industry for 5 years or
Yes
No
more?
Do you have Social Security credits (for example, based on work or
14.
(a)
Yes
No
residence) under another country's Social Security System?
(If "Yes," answer
(If "No," go to
(b).)
item 15.)
(b) List the country(ies):
15.
(a) Are you entitled to, or do you expect to become entitled to, a pension or
Yes (If "Yes,"
No (If "No," go
annuity based on your work after 1956 not covered by Social Security?
answer (b) and (c).)
on to item 16.)
MONTH
YEAR
(b)
I became entitled, or expect to become entitled, beginning
MONTH
YEAR
(c)
I became eligible, or expect to become eligible, beginning
I AGREE TO PROMPTLY NOTIFY the Social Security Administration if I become entitled to a pension or annuity
based on my employment after 1956 not covered by Social Security, or if such pension of annuity stops.
16. (a) Have you ever been married?
Yes
No
Go to (b)
Go to item 17
(b) To whom married
When (Month, day, year)
Where (Name of City and State)
How marriage ended (If still in
When (Month, day, year)
Where (Name of City and State)
effect, write "Not Ended.")
Current or
Marriage performed by:
Spouse's date of birth (or age)
If spouse deceased, give date of death
Last
Clergyman or public official
Marriage
Other (Explain in Remarks)
/
/
Spouse's Social Security Number (If none or unknown, so indicate)
Give the following information about each of your previous marriages. (If none, write ''NONE.'')
(c) To whom married
When (Month, day, year)
Where (Name of City and State)
How marriage ended
When (Month, day, year)
Where (Name of City and State)
Your
Marriage performed by:
Spouse's date of birth (or age)
If spouse deceased, give date of death
previous
Clergyman or public official
marriage
Other (Explain in Remarks)
/
/
Spouse's Social Security Number (If none or unknown, so indicate)
Use "Remarks" space for information about any other marriages.
Form SSA-16-BK (05-2006)
EF (12-2008)
Page 2
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