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Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 5

REMARKS (You may use this space for any explanation. If you need more space, attach a separate sheet.)

I declare under penalty of perjury that I have examined all the information on the form and any accompanying

statements or forms, and it is true and correct to the best of my knowledge.

Date (Month, Day, Year)

SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number(s) at which you may be contacted

during the day. (Include the area code)

SIGN

HERE

Direct Deposit Payment Address (Financial Institution)

FOR

Routing Transit Number

C/S Depositor Account Number

OFFICIAL

No Account

USE ONLY

Direct Deposit Refused

Applicant's Mailing Address

(Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in "Remarks," if different.)

City and State

ZIP Code

County (if any) in which you now live

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the

signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's name in Signature block.

1. Signature of Witness

2. Signature of Witness

Address

(Number and street, City, State and ZIP Code)

Form SSA-16-BK (05-2006)

EF (12-2008)

Page 5

Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 5