Application for Disability Insurance Benefits
Form SSA-16-BK (01-2015) ef (01-2015)
Do you have a dependent parent who was receiving at least one-half
support 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".
(a) Did you receive any money from an employer(s) on or after the
date in item 9 when you became unable to work because of your
illnesses, injuries, or conditions? If "Yes", give the amounts and
explain in "Remarks".
Page 4
22.
(a) Are you still unable to work because of your illnesses, injuries, or
conditions?
(If "Yes," go to item 23) (If "No," answer (b))
MONTH, DAY, YEAR
23.
Are your illnesses, injuries, or conditions related to your work in
any way?
24. (a) Have you filed, or do you intend to file, for any other public
disability benefits (including workers' compensation, Black Lung
benefits and SSI)?
(If "Yes," answer (b))
(If "No," to item 25)
(b) The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply):
Veterans Administration Benefits
Supplemental Security Income
Welfare
Other
(If "Other," complete a Workers' Compensation/Public
Disability Benefit Questionnaire)
25.
Amount $
(b) Do you expect to receive any additional money from an employer,
such as sick pay, vacation pay, other special pay? If "Yes," please
give amounts and explain in "Remarks".
Amount $
26. Do you, or did you, have a child under age 3 (your own or your spouse's)
living with you in one or more calendar years when you had no earnings?
27.
28. 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, check "Unknown").
Yes No
Yes No
Yes No
No Yes
No Yes
(b) Enter the date you became able to work.
Yes No
Yes No
Yes No
Unknown
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