Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 3

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17.
If your claim for disability benefits is approved, your children (including natural children, adopted children, and
stepchildren) or dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on your earnings
record.
List below: FULL NAME OF ALL such children who are now or were in the past 12 months UNMARRIED and:
 UNDER AGE 18
 AGE 18 TO 19 AND ATTENDING ELEMENTARY OR SECONDARY SCHOOL FULL-TIME
 DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
18. (a) Did you have wages or self-employment income covered under
Yes
No
Social Security in all years from 1978 through last year?
(If "Yes," go to item 19.)
(If "No," answer (b).)
(b) List the years from 1978 through last year in which you did not have
wages or self-employment income covered under Social Security.
19. (a) Enter below the names and addresses of all the persons, companies, or Government agencies for whom you have
worked this year and last year. IF NONE, WRITE "NONE" BELOW AND GO TO ITEM 20.
Work Ended
NAME AND ADDRESS OF EMPLOYER
Work Began
(If still working
(If you had more than one employer, please list them
show "Not Ended")
in order beginning with your last (most recent) employer)
MONTH
YEAR
MONTH
YEAR
(If you need more space, use "Remarks".)
(b) Are you an officer of a corporation or related to an officer of a
Yes
No
corporation?
20. May the Social Security Administration or State agency reviewing
your case, ask your employers for information needed to process the
Yes
No
claim?
Complete item 21 even if you were an employee.
21.
Yes
No
(a) Were you self-employed this year or last year?
Go to (b)
Go to item 22
(b) Check the year (or years)
In what type of trade/business
Were your net earnings from the
were you self-employed?
trade or business $400 or more?
you were self-employed
(For example, storekeeper, farmer, physician)
(Check "Yes" or "No")
This year
Yes
No
Last year
22. (a) How much were your total earnings last year? Count both wages and
Amount $
self-employment income. (If none, write "None.")
(b) How much have you earned so far this year? (If none, write
Amount $
"None.")
23.
Check if applicable:
Please compute my benefits and complete my claim without using recent earnings that are not yet included on my
(the deceased's, if applicable) earnings record. I understand that the earnings record will be updated automatically within
24 months and that any increase in benefits resulting from these earnings will be paid with the full retroactivity.
Form SSA-16-BK (05-2006)
EF (12-2008)
Page 3

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