Application for Disability Insurance Benefits
(d) Enter information about any marriage if you:
Form SSA-16-BK (01-2015) ef (01-2015)
(c) Enter information about any other marriage if you:
Where (Name of City and State)
• Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the
combined period of marriage totaled 10 years or more. If none, write "None." Go on to item 15(d) if
you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before
age 22) and you are divorced from the child's other parent who is now deceased and the marriage lasted less than 10 years.
Where (Name of City and State)
(a) Were you in the active military or naval service (including Reserve
or National Guard active duty or active duty for training) after
September 7, 1939 and before 1968?
Page 2
11.
(If "Yes," answer
(b) and (c))
(If "No," go to
item 12)
(b) Enter dates of service
FROM: (Month, Year) TO: (Month, Year)
(c) Have you ever been (or will you be) eligible for a monthly benefit
from a military or civilian Federal agency? (Include Veteran's
Administration benefits only if you waived military retirement pay.)
12.
Did you or your spouse (or prior spouse) work in the railroad industry for 5
years or more?
13.
(a) Do you have Social Security credits (for example, based on work
or residence) under another country's Social Security System?
(If "Yes," answer (b)) (If "No," go to item 14)
(b) List the country(ies):
14.
(a) Are you entitled to, or do you expect to be entitled to, a pension or
annuity (or a lump sum in place of a pension or annuity) based on
your work after 1956 not covered by Social Security?
(If "Yes," answer
(b) and (c))
(b) I became entitled, or expect to become entitled, beginning
MONTH YEAR
(c) I became eligible, or expect to become eligible, beginning
MONTH YEAR
I AGREE TO PROMPTLY NOTIFY the Social Security Administration if I become entitled to a pension or
annuity based on my employment not covered by Social Security, or if such pension or annuity stops.
15.
(a) Have you ever been married?
If "No," go to item 16)
(b) Give the following information about your current marriage. If not currently married,
write "None." (If "None," go on to item 15(c))
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of birth
(or age)
Spouse's Social Security Number
(If none or unknown, so indicate)
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)
How marriage ended When (Month, day, year) Where (Name of City and State)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of birth
(or age)
Date of spouse's death Spouse's Social Security Number
(If none or unknown, so indicate)
• Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22); and
• Were married for less than 10 years to the child's mother or father, who is now deceased; and
• The marriage ended in divorce
If none, write "None."
Date of divorce (Month, day, year) Where (Name of City and State)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of birth
(or age)
Date of spouse's death Spouse's Social Security Number
(If none or unknown, so indicate)
No Yes
No Yes
No
Yes
No Yes
No Yes
No Yes
Spouse's name (including maiden name) When (Month, day, year)
Spouse's name (including maiden name) When (Month, day, year)
(If "No," go to item 12)
(If "Yes," answer (b))
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