Fillable Form SSA-16 (07-2017) UF: APPLICATION FOR DISABILITY INSURANCE (Grossman Law Firm LLC.)

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Form SSA-16 (07-2017) UF: APPLICATION FOR DISABILITY INSURANCE (Grossman Law Firm LLC.)

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Form SSA-16 (07-2017) UF
Discontinue prior editions
Social Security Administration
APPLICATION FOR DISABILITY INSURANCE BENEFITS
Page 1 of 7
OMB No. 0960-0618
TEL
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.
(Do not write in this space)
1. PRINT your name
FIRST NAME, MIDDLE INITIAL, LAST NAME
2.
Enter your Social Security Number
3.
Check (X) whether you are
Female Male
Answer question 4 if English is not your preferred language. Otherwise, go to item 5.
4.
Enter the language you prefer to: speak write
5.
(a) Enter your date of birth
(b) Enter name of city and state or foreign country where you
were born.
(c) Was a public record of your birth made before you were age 5?
Yes No Unknown
(d) Was a religious record of your birth made before you were
age 5?
Yes No Unknown
6.
(a) Are you a U.S. citizen?
Yes
(If "Yes," go to item 7)
No
(If "No," answer (b))
(b) Are you an alien lawfully present in the U.S.?
Yes
(If "Yes," answer (c))
No
(If "No," go to item 7)
(c) When were you lawfully admitted to the U.S.?
7.
(a) Enter your name at birth if different from item (1)
(b) Have you used any other names?
Yes
(If "Yes," answer (c))
No
(If "No," go to item 8)
(c) Other name(s) used.
8.
(a) Have you used any other Social Security number(s)?
Yes
(If "Yes," answer (b))
No
(If "No" go to item 9)
(b) Enter Social Security number(s) used.
9.
When do you believe your condition(s) became severe enough to
keep you from working (even if you have never worked)?
10.
(a) Have you (or has someone on your behalf) ever filed an
application for Social Security benefits, a period of disability
under Social Security, Supplemental Security Income, or
hospital or medical insurance under Medicare?
Yes
(If "Yes," answer
(b) and (c))
No Unknown
(If "No," or "Unknown,"
go to item 11)
(b) Enter name of person on whose Social Security
record you filed the other application.
(c) Enter Social Security Number of person named
in (b). If unknown, check this block.
Unknown
Form SSA-16 (07-2017) UF
Page 2 of 7
11.
(a) 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) and (c))
No
(If "No," go to
item 12)
(b) Enter dates of service
FROM: (Month, Year) TO: (Month, Year)
(c) Have you ever been (or will you be) eligible for a monthly
benefit from a military or civilian Federal agency? (Include
Veteran's Administration benefits only if you waived military
retirement pay.)
Yes No
12. Did you or your spouse (or prior spouse) work in the railroad
industry for 5 years or more?
Yes No
13. (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 14)
(b) List the country(ies):
14. (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 your work after 1956 not covered by Social Security?
Yes
(If "Yes," answer
(b) and (c))
No
(If "No," go to item 15)
(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.
15.
(a) Have you ever been married?
Yes
(If "Yes," answer (b))
No
(If "No," go to item 16)
(b) Give the following information about your current marriage. If not currently married,
write "None." (If "None," go on to item 15(c))
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of birth (or age) Spouse's Social Security Number
(If none or unknown, so indicate)
(c) Enter information about any other marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
• Were divorced, remarried the same individual within the year immediately following the year of the divorce, and
the combined period of marriage totaled 10 years or more. If none, write "None." Go on to item 15
(d) if you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began
before age 22) and you are divorced from the child's other parent who is now deceased and the marriage lasted
less than 10 years.
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)
How marriage ended When (Month, day, year) Where (Name of City and State)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of
birth (or age)
Date of spouse's death
Spouse's Social Security Number
(If none or unknown, so indicate)
Form SSA-16 (07-2017) UF
Page 3 of 7
15. (d) Enter information about any marriage if you:
• Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before
age 22); and
• Were married for less than 10 years to the child's mother or father, who is now deceased; and
• The marriage ended in divorce
If none, write "None."
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)
Date of divorce (Month, day, year) Where (Name of City and State)
Marriage performed by:
Clergyman or public official
Other (Explain in Remarks)
Spouse's date of birth
(or age)
Date of spouse's death Spouse's Social Security Number
(If none or unknown, so indicate)
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?
Yes
(If "Yes," go to item 18)
No
(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
Work Ended (If still
working show
"Not Ended")
MONTH YEAR
(If you need more space, use "Remarks".)
Form SSA-16 (07-2017) UF
Page 4 of 7
19. May the Social Security Administration or State agency reviewing
your case, ask your employers for information needed to process
the claim?
Yes No
20.
Complete item 20 even if you were an employee.
(a) Were you self-employed this year or last year?
Yes
(If "Yes," answer (b))
No
(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 Yes No
21. (a) How much were your total earnings last year?
Count both wage and self-employment income.
(If none, write "None.")
Amount $
(b) How much have you earned so far this year?
(If none, write "None.")
Amount $
22.
(a) Are you still unable to work because of your illnesses, injuries,
or conditions?
Yes
(If "Yes," go to item 23)
No
(If "No," answer (b))
(b) Enter the date you became able to work.
MONTH, DAY, YEAR
23.
Are your illnesses, injuries, or conditions related to your work in
any way?
No Yes
(a) Have you filed, or do you intend to file, for any other public
disability benefits (including workers' compensation, Black Lung
benefits and SSI)?
24.
Yes
(If "Yes," answer (b))
No
(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. (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".
Yes No
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".
Yes No
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?
Yes No
27. 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".
Yes No
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 Unknown
Form SSA-16 (07-2017) UF
Page 5 of 7
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 this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives
a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
subject to a fine or imprisonment.
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
Date (Month, Day, Year)
Telephone Number(s) at which you
may be contacted during the day.
(Include the area code)
DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)
Routing Transit Number Account 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 (07-2017) UF
Page 6 of 7
FOR YOUR INFORMATION
An agency in your State that works with us in administering the Social Security disability program is
responsible for making the disability decision on your claim. In some cases, it is necessary for them to get
additional information about your condition or to arrange for you to have a medical examination at
Government expense.
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, 223 and 1872 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an
accurate and timely decision on any claim filed.
We will use the information to make a determination of eligibility for benefits for you and your dependents. We may
also share your information for the following purposes, called routine uses:
1. To State audit agencies for auditing State supplementation payments and Medicaid eligibility
considerations; and
2. To the Social Security agency of a foreign country, to carry out the purpose of an international Social
Security agreement entered into between the United States and the other country, pursuant to section 233
of the Social Security Act.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records
are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for
repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0059, entitled
Earnings Recording and Self-Employment Income System and 60-0089, entitled Claims Folders Systems.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 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 20 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also 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.
Form SSA-16 (07-2017) UF
Page 7 of 7
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS
Person to Contact About Your Claim
Telephone Number (Include Area Code)
SSA OFFICE Date Claim Received
Your application for Social Security disability benefits has
been received and will be processed as quickly
as possible.
You should hear from us within days after you
have given us all the information we requested. Some
claims may take longer if additional information is needed.
In the meantime, if you change your address, or if there
is some other change that may affect your claim, you - or
someone for you - should report the change. The changes
to be reported are listed below.
Always give us your claim number when writing or
telephoning about your claim.
If you have any questions about your claim, we will be glad
to help you.
CLAIMANT SOCIAL SECURITY CLAIM NUMBER
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID
• You change your mailing address for checks or
residence. To avoid delay in receipt of checks you
should ALSO file a regular change of address notice with
your post office.
• Your citizenship or immigration status changes.
• You go outside the U.S.A. for 30 consecutive days or
longer.
• Any beneficiary dies or becomes unable to
handle benefits.
• Custody Change - Report if a person for whom you are
filing or who is in your care dies, leaves your care or
custody, or changes address.
• You are confined to a jail, prison, penal institution or
correctional facility for more than 30 continuous days for
conviction of a crime, or you are confined for more than
30 continuous days to a public institution by a court order
in connection with a crime.
• You become entitled to a pension, an annuity, or a lump
sum payment based on your employment not covered by
Social Security, or if such pension or annuity stops.
• Your stepchild is entitled to benefits on your record and
you and the stepchild's parent divorce. Stepchild benefits
are not payable beginning with the month after the month
the divorce becomes final.
• You have an unsatisfied warrant for more than 30
continuous days for your arrest for a crime or attempted
crime that is a felony of flight to avoid prosecution or
confinement, escape from custody and flight-escape. In
most jurisdictions that do not classify crimes as felonies,
this applies to a crime that is punishable by death or
imprisonment for a term exceeding one year (regardless
of the actual sentence imposed).
• You have an unsatisfied warrant for more than 30
continuous days for a violation of probation or parole
under Federal or State law.
• Change of Marital Status - Marriage, divorce, annulment
of marriage.
• If you become the parent of a child (including an adopted
child) after you have filed your claim, let us know about
the child so we can decide if the child is eligible for
benefits. Failure to report the existence of these children
may result in the loss of possible benefits to
the child(ren).
• You return to work (as an employee or self-employed)
regardless of amount of earnings.
• Your condition improves.
• You are under age 65 and you apply for or begin to
receive workers' compensation (including black lung
benefits) or another public disability benefit, or the
amount of your present workers' compensation or public
disability benefit changes or stops, or you receive a
lump-sum settlement.
HOW TO REPORT
You can make your reports online, by telephone, mail, or in person, whichever you prefer. If you are awarded benefits, and
one or more of the above change(s) occur, you should report by:
• Visiting the section "my Social Security" at our web site at www.socialsecurity.gov;
• Calling us TOLL FREE at 1-800-772-1213;
• If you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or
• Calling, visiting or writing your local Social Security office at the phone number and address shown on your
claim receipt.
For general information about Social Security, visit our web site at www.socialsecurity.gov.
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Completed 29 March 2021

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