Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 4
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724.
What are the illnesses, injuries, or conditions that limit your ability to work? (Give a brief description.)
25.
Yes
No
(a) Are you still unable to work because of your illnesses, injuries, or
conditions?
Go to item 26
Go to (b)
(b) Enter the date you became able to work.
MONTH, DAY, YEAR
IMPORTANT INFORMATION ABOUT DISABILITY INSURANCE BENEFITS
PLEASE READ CAREFULLY
SUBMITTING MEDICAL EVIDENCE: I understand that I must provide medical evidence about my
disability and I may be asked to assist the Social Security Administration in obtaining the evidence. I
understand that I may be requested by the State Disability Determination Services to have a
consultative examination at the expense of the Social Security Administration and that if I do not go,
my claim may be denied.
26.
Are your illnesses, injuries, or conditions related to your
Yes
No
work in any way?
27. (a) Have you filed, or do you intend to file, for any other public disability
Yes
No
benefits (including workers' compensation, Black Lung benefits and
SSI)?
Go to(b)
Go to item 28
(b) The other public disability benefit(s) you have filed (or intend to file)
for is (Check as many as apply):
Veterans Administration Benefits
Welfare
Supplemental Security Income (SSI)
Other (If "Other," complete a Workers' Compensation/Public
Disability Benefit Questionnaire)
28.
(a) Did you receive any money from an employer(s) on or after the date
Yes
No
in item 10 when you became unable to work because of your
illnesses, injuries, or conditions? If "Yes", give the amounts and
explain in "Remarks".
Amount $
(b) Do you expect to receive any additional money from an employer, such
Yes
No
as sick pay, vacation pay, other special pay? If "Yes," please give
amounts and explain in "Remarks".
Amount $
29. Do you, or did you, have a child under age 3 (your own or your spouse's)
Yes
No
living with you in one or more calendar years when you had no earnings?
30. Do you have a dependent parent who was receiving at least one-half support
Yes
No
from you when you became unable to work because of your disability? If
"Yes," enter the parent's name and address and Social Security number, if
known, in "Remarks".
31. If you were unable to work before age 22 because of an illness, injury or condition, do you have a parent (including
adoptive or stepparent) or grandparent who is receiving social security retirement or disability benefits or who is
deceased? If yes, enter the name(s) and Social Security number, if known, in "Remarks" (if unknown, write "Unknown").
32. Do you have any unsatisfied felony warrants for your arrest?
Yes
No
Do you have any unsatisfied Federal or State warrants for your arrest for
Yes
No
33.
violating the conditions of your probation or parole?
Form SSA-16-BK (05-2006)
EF (12-2008)
Page 4
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