Form SSA-16-BK (11-2022) UF
Page 1 of 7
OMB No. 0960-0618
APPLICATION FOR DISABILITY INSURANCE BENEFITS
I apply for a period of disability and/or all insurance benefits for which I am eligible under Title II and Part A of Title XVIII of the Social Security Act, as presently amended.
1.
PRINT your name:
2.
Enter your Social Security Number:
3.
Answer question 3 in English or in your preferred language. Otherwise, go to item 4.
What language you prefer to:
4.
(a) Enter your date of birth:
(b) Enter name of city and state or foreign country where you were born:
5.
(a) Are you a U.S. citizen?
Yes No
(b) Are you or were you a citizen? (If "Yes," answer (c))
Yes No
6.
(a) Are you currently present in the U.S.?
Yes No
(b) When were you lawfully admitted to the U.S.?
(c) When you were lawfully admitted to the U.S. as a permanent resident (or alien)?
7.
(a) Have you used any other Social Security numbers?
Yes (If "Yes," answer (b)) No (If "No," go to item 8)
(b) Enter Social Security number(s) used:
8.
When do you believe your condition became severe enough to:
(a) Keep you from doing any work?
(b) Did you or your spouse (or prior spouse) work in railroad industry for 5 years or more?
Yes No
9.
(a) Do you have Social Security credits (for example, based on work or residence) under another country's Social Security System?
Yes No
(b) Other name(s) used:
10.
(a) Do you have Social Security credits (for example, based on work or residence) under another country's Social Security System?
Yes (If "Yes," answer (b)) No (If "No," go to item 11)
11.
(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 employment after 1956 not covered by Social Security?
Yes (If "Yes," answer No (If "No," go to item 12)
(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.
Form SSA-16-BK (11-2022) UF
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12.
Have you ever been married?
Yes (If "Yes," answer (b)) No (If "No," go to item 13)
(b) Give the following information about your current marriage. If not currently married, show your last marriage below.
To whom married When (Month, day, year) Where (Name of City and State)
How did this marriage end (if still married, write "Not ended")?
When did this marriage end? Month Day Year
If you had more than one marriage, list information about each of your prior marriages.
To whom married When (Month, day, year) Where (Name of City and State) How marriage ended When it ended (Month, day, year)
13.
List below FULL NAME of all your children (including natural children, adopted children, and stepchildren) who are now or were in the past dependent upon you for support AND who are:
  • UNMARRIED and under age 18;
  • UNMARRIED and age 18 or over and disabled or handicapped (age 22 or over and disabled before age 22); OR
  • UNMARRIED and age 18-19 and attending elementary or secondary school as a full-time student.
If you have no such children, write "NONE" below and go to item 14.
FULL NAME OF CHILD PLACE OF BIRTH (City and State or Foreign Country) DATE OF BIRTH (Month, day, year) RELATIONSHIP TO YOU (Natural, adopted, step) CHILD'S SOCIAL SECURITY NUMBER (if known) DISABLED? (Yes or No) ATTENDING SCHOOL? (Yes or No) MARRIED? (Yes or No)
Form SSA-16-BK (11-2022) UF
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14.
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?
Yes (If "Yes," answer (b) below) No (If "No," go to item 15)
(b) Enter dates of service: From: To:
15.
Answer this item ONLY if you are within 5 months of age 62 or older.
Do you want your disability benefits to be converted automatically to retirement benefits when you reach full retirement age?
Yes No
16.
List all jobs (including self-employment) that you have had in the 15 years before the month you became unable to work. BEGIN with your last job first. If you need more space, use "Remarks."
A. DATES WORKED B. TYPE OF BUSINESS OR INDUSTRY C. JOB TITLE AND DESCRIPTION OF WORK
From: (Month/Year)


To: (Month/Year)
From: (Month/Year)


To: (Month/Year)
From: (Month/Year)


To: (Month/Year)
17.
May we contact your employers for wage information?
Yes No
If "No," please explain:
18.
Were you unable to work because of your disabling condition from through but later became able to work again?
Yes No
19.
Did you receive, or do you expect to receive, any money (including vacation or sick pay) from an employer for any period after you became unable to work?
Yes (If "Yes," please explain in "Remarks") No
20.
Are you receiving, or do you expect to receive, Workers' Compensation (including Black Lung payments) or other public disability benefits?
Yes (If "Yes," complete a Workers' Compensation/Public Disability Benefit Questionnaire) No
Form SSA-16-BK (11-2022) UF
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21.
Have you ever filed an application for Social Security, Supplemental Security Income, Hospital or Medical Insurance benefits, or a period of disability with Social Security, the Railroad Retirement Board, or any other agency?
Yes (If "Yes," answer (b)) No (If "No," go to item 22)
(b) List the name(s) of person(s) on whose Social Security record you filed other application(s):
22.
FOR MEDICAL INFORMATION
A. List the names, addresses, and telephone numbers of all the doctors, hospitals, clinics, or other health care providers who have examined, treated, or consulted about your disabling condition(s). Also show the approximate dates of treatment and the types of treatment received.
NAME AND ADDRESS OF HEALTH CARE PROVIDER TELEPHONE NUMBER DATES OF TREATMENT TYPE OF TREATMENT RECEIVED
B. List any medicine you are taking for your disabling condition(s):
C. Have you been seen by a doctor or other health care provider for emotional or mental problems that limit your ability to work?
Yes (If "Yes," give name and address of doctor(s) or provider(s)) No
D. Have you been in the hospital overnight or longer for your disabling condition(s)?
Yes (If "Yes," give name and address of hospital(s) and dates) No
Form SSA-16-BK (11-2022) UF
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23.
CONTACTS
Give the name of a friend or relative who knows about your disabling condition(s) and can be contacted if we need more information.
Name:

Address:



Telephone Number:
Relationship to you:
24.
REMARKS
Use this space for any explanation. If you need more space, attach a separate sheet.
I know that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF APPLICANT
Date (Month, day, year)
TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY
MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)
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 and provide their full addresses.
1. Signature of Witness
Address (Number and street, City, State, ZIP Code)
2. Signature of Witness
Address (Number and street, City, State, ZIP Code)
Form SSA-16-BK (11-2022) UF
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FOR SOCIAL SECURITY ADMINISTRATION USE ONLY
The information contained in this section is not available for public use or disclosure and may be used only for authorized program purposes.
Document Locator Number (DLN)
 Office Code
Routing Transit Number
 Account Number
Checking
Savings
EVIDENCE
EVIDENCE, HOW OBTAINED, ETC. DISPOSITION
DETERMINATION ON DISABILITY
Allowance
Denial
Established Onset Date:
Signature and Title of Authorizing Official:
Date:
REMARKS
Form SSA-16-BK (11-2022) UF
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PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE
Sections 205(a), 702(a)(5), and 1631(d)(1) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide us with requested information may prevent us from making an accurate and timely decision on your claim, and could result in the loss of some benefits.
We will use the information you provide to determine if you qualify for benefits. We may also share your information for the following purposes, called routine uses:
  • To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in the administration of its programs;
  • To student volunteers and other workers, who technically do not have the status of Federal employees, when they are performing work for the Social Security Administration, as authorized by law, and they need access to personally identifiable information in our records in their assigned duties;
  • To the Department of Justice or a court, when the Government is a party to a judicial proceeding;
  • To another person or governmental agency in connection with an applicant's or beneficiary's eligibility for benefits administered by us;
  • To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of our programs;
  • To members of Congress, or staff acting upon their request, when the Congressional office has received a specific inquiry from the constituent who is the subject of the record;
  • To the Department of Health and Human Services for determining conformity with or monitoring compliance under the Medicaid program;
  • To Federal, State, or local agencies for investigating suspected fraud, abuse, or civil or criminal violations of law; and
  • To Federal, State, and local agencies for administration of food stamps, supplemental nutrition assistance, Medicaid, unemployment compensation, workers' compensation, veteran's compensation, and public assistance programs.
Disclosure of this information is mandatory to receive Social Security benefits. We may also use the information you give us when we match records by computer. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. ยง 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
DESTROY PRIOR EDITIONS
Social Security Administration
Form SSA-16-BK (11-2022)