Application for Retirement Insurance Benefits
2.
WriteSpeak
1.
(b) Enter Social Security number(s) used.
(a) Have you used any other name(s)?
(b) Check (X) whether you are
Answer question 3 if English is not your language preference. Otherwise, go to item 4.
Enter the language you prefer to:
(a) Enter your date of birth
Enter your Social Security number
FIRST NAME, MIDDLE INITIAL, LAST NAME(a) PRINT your name
Page 1 (Over)
Yes
No
(d) Was a religious record of your birth made before you were age 5?
Yes No Unknown
(c) Was a public record of your birth made before you were age 5?
Yes No Unknown
Male Female
(b) Enter name of city and state, or foreign country where
you were born.
Enter your full name at birth if different from
item 1(a)
FIRST NAME, MIDDLE INITIAL, LAST NAME
Yes No
8. (a) Have you used any other Social Security number(s)?
6.
Month, Day, Year
NoYes
(a) Are you a U.S. citizen?
(b) Are you an alien lawfully present in U.S.?
(b) Other names(s) used.
(Go to item 7.) (Go to item (b).)
(Go to item (b).) (Go to item 8.)
(Go to item (b)) (Go to item 9.)
3.
4.
5.
7.
Form Approved
OMB No. 0960-0618
TEL TOE 120/145/155
SOCIAL SECURITY ADMINISTRATION
APPLICATION FOR RETIREMENT INSURANCE BENEFITS
I apply for all insurance benefits for which I am eligible under Title II (Federal Old-Age,
Survivors, and Disability Insurance) and Part A of Title XVIII (Health Insurance for the
Aged and Disabled) of the Social Security Act, as presently amended.
Supplement. If you have already completed an application entitled
"APPLICATION FOR WIFE'S OR HUSBAND'S INSURANCE BENEFITS",
you need complete only the circled items. All other claimants must complete
the entire form.
(Do not write in this space)
(c) When were you lawfully admitted to the U.S.?
Yes No
(Go to item (c)) (Go to item 6)
Form SSA-1-BK (02-2014) ef (02-2014)
Destroy prior editions
Page 1/8
Free Download
Application for Retirement Insurance Benefits PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
