Application for Disability Insurance Benefits
Form SSA-16-BK (01-2015) ef (01-2015)
(a) How much were your total earnings last year?
Count both wage and self-employment income.
(If none, write "None.")
(If you need more space, use "Remarks".)
Page 3
Use the "REMARKS" space on page 5 for marriage continuation or explanation.
16. If your claim for disability benefits is approved, your children (including 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)
17.
(a) Did you have wages or self-employment income covered under
Social Security in all years from 1978 through last year?
(If "Yes," go to item 18)
(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.
18. 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 19.
NAME AND ADDRESS OF EMPLOYER
(If you had more than one employer, please list them
in order beginning with your last (most recent) employer)
Work Began
MONTH YEAR MONTH YEAR
19. May the Social Security Administration or State agency reviewing your case, ask your employers
for information needed to process the claim?
20.
Complete item 20 even if you were an employee.
(a) Were you self-employed this year or last year?
(If "Yes," answer (b))
(If "No," go to item 21)
(b) Check the year (or
years) you were
self-employed
In what type of trade/business
were you self-employed?
(For example, storekeeper, farmer,
physician)
Were your net earnings from the
trade or business $400 or more?
(Check "Yes" or "No")
This year
Last year
21.
(b) How much have you earned so far this year? (If none, write
"None.")
Amount $
No Yes
Work Ended (If still
working show
"Not Ended")
No Yes
No Yes
No Yes
Amount $
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