Application for Disability Insurance Benefits

Enter the language you prefer to:
Answer question 4 if English is not your preferred language. Otherwise, go to item 5.
(a) Are you a U.S. citizen?
(c) Other name(s) used.
(b) Enter name of person on whose Social Security
record you filed the other application.
(b) Have you used any other names?
(a) Have you used any other Social Security number(s)?
(b) Enter Social Security number(s) used.
PRINT your name
SOCIAL SECURITY ADMINISTRATION
Form SSA-16-BK (01-2015) ef (01-2015)
Destroy prior editions
APPLICATION FOR DISABILITY INSURANCE BENEFITS
Form Approved
OMB No. 0960-0618
Page 1
TEL TOE 120/145
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.
(Do not write in this space)
1.
2. Enter your Social Security Number
3. Check (X) whether you are
4.
5. (a) Enter your date of birth
(b) Enter name of city and state or foreign country where you
were born.
(d) Was a religious record of your birth made before you were age
5?
6.
(If "No," answer (b))
(b) Are you an alien lawfully present in the U.S.?
(If "No," go to item 7)
(If "No," go to item 8)
(a) Have you (or has someone on your behalf) ever filed an
application for Social Security benefits, a period of disability
under Social Security, Supplemental Security Income, or
hospital or medical insurance under Medicare?
(If "Yes," answer
(b) and (c))
(If "No," or "Unknown,"
go to item 11)
(c) Enter Social Security Number of person named
in (b). If unknown, check this block.
FIRST NAME, MIDDLE INITIAL, LAST NAME
speak write
Yes No Unknown
Unknown No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
MaleFemale
Unknown
When do you believe your condition(s) became severe enough to
keep you from working (even if you have never worked)?
(c) Was a public record of your birth made before you were age 5?
8.
7. (a) Enter your name at birth if different from item (1)
9.
(c) When were you lawfully admitted to the U.S.?
(If "Yes," go to item 7)
(If "Yes," answer (c))
(If "Yes," answer (b))
(If "No" go to item 9)
(If "Yes," answer (c))
Unknown
Page 1/7
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Application for Disability Insurance Benefits PDF

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