Application for Disability Insurance Benefits
Telephone Number(s) at which you
may be contacted during the day.
(Include the area code)
Account Number
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.
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, Day, Year)
DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)
Routing Transit Number
Checking
Savings
Enroll in Direct Express
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
Address (Number and street, City, State and ZIP Code)
2. Signature of Witness
Address (Number and street, City, State and ZIP Code)
Form SSA-16-BK (01-2015) ef (01-2015)
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