Fillable Ssa-1-bk Application For Retirement Insurance Benefits

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Ssa-1-bk Application For Retirement Insurance Benefits

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Form SSA-1-BK (06-2018) UF
Discontinue Prior Editions
Social Security Administration
2.
Write
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
(Over)
(d) Was a religious record of your birth made before you were age 5?
(c) Was a public record of your birth made before you were age 5?
Male
(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)
8. (a) Have you used any other Social Security number(s)?
6.
Month, Day, Year
(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.
Page 1 of 9
OMB No. 0960-0618
TEL
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.?
(Go to item (c)) (Go to item 6)
Female
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Unknown
Unknown
FIRST NAME, MIDDLE INITIAL, LAST NAME
(a) PRINT your name
Form SSA-1-BK (06-2018) UF
11.
10.
12.
13.
(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?
Did you or your spouse (or prior spouse) work in the railroad industry
for 5 years or more?
(a) Do you (or your spouse) have Social Security credits (for example
based on work or residence) under another country's Social
Security system?
9.
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) If "Yes", enter the date you became unable to work.
(b) Enter date(s) of service
(c) Are you (or your spouse) filing for foreign Social Security benefits?
14.
(If "No," go on
to item 15.)
(If "Yes,"
answer (b)
and (c).)
(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?
(b) I became entitled, or expect to become entitled, beginning
(c) I became eligible, or expect to become eligible, beginning
MONTH, DAY, YEAR
MONTH
MONTH
YEAR
YEAR
(If "No," go
to item 11.)
(If "No," go
to item 12.)
(If "No," go
to item 14.)
(If "Unknown,"
go to item 11.)
(If "Yes,"
answer (b)
and (c).)
(If "Yes," answer
(b) and (c).)
(If "Yes,"
answer (b)
and (c).)
Do not answer question 9 if you are one year past full retirement age or older; go to question 10.
(a) Have you (or has someone on your behalf) ever filed an
application for Social Security, Supplemental Security
Income, or hospital or medical insurance under Medicare?
(c) Enter Social Security number(s) of person named in (b).
(If unknown, so indicate.)
Month, Year Month, Year
(b) List the country(ies):
From: To:
Answer question 14 only if you were born January 2, 1924, or later. Otherwise go on to question 15.
I agree to promptly notify the Social Security Administration if I become entitled
to a pension, an annuity, or a lump sum payment based on my employment not
covered by Social Security, or if such pension or annuity stops.
(b) Enter name of person(s) on whose Social Security record
you filed other application.
(c) Have you ever been (or will you be) eligible for monthly benefits
from a military or civilian Federal agency? (Include Veterans
Administration benefits only if you waived Military retirement pay).
Page 2 of 9
(a) Are you, or during the past 14 months have you been,
unable to work because of illnesses, injuries or conditions?
UnknownNoYes
NoYes
NoYes
NoYes
Yes No
NoYes
NoYes
NoYes
Spouse's date of birth (or age)
Form SSA-1-BK (06-2018) UF
15.
(a) Give the following information about your current marriage. If not currently married, write "None"
Go on to item 16(b).
Spouse's Social Security number (If none or unknown, so indicate)
Marriage performed by:
Spouse's name (including maiden name)
When (Month, day, year)
Where (Name of City and State)
Spouse's date of birth (or age)
Where (Name of City and State)
(b) Enter information about any other marriage if you:
• Had a marriage that lasted at least 10 years; 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.
16.
How marriage ended (If still in effect, write
"Not Ended.")
(If "Yes," answer item 16.) (If "No," go to item 17.)
If your claim for retirement benefits is approved, your children (including adopted children and stepchildren) or
dependent grandchildren (including step grandchildren) may be eligible for benefits based on your earnings record.
Spouse's name (including maiden name) Where (Name of City and State)
(c) 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."
Use the 'Remarks' space on page 6 for marriage continuation or explanation.
Have you been married?
• Had a marriage that ended due to death of your spouse, regardless of duration; or
Use the "Remarks" space to enter the additional marriage information. If none, write "None." Go on to item 16 (c) 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 Social Security number (If none or unknown, so indicate)
Marriage performed by:
Where (Name of City and State)
How marriage ended
To whom married Where (Name of City and State)
Spouse's Social Security number (If none or unknown, so indicate)
Marriage performed by:
Where (Name of City and State)
Spouse's date of birth (or age)
How marriage ended
(Turn to Page 4)
Page 3 of 9
NoYes
Clergyman or public official
Other (Explain in "Remarks")
Other (Explain in "Remarks")
Clergyman or public official
Other (Explain in "Remarks")
Clergyman or public official
When (Month, day, year)
If spouse deceased, give date of death
When (Month, day, year)
If spouse deceased, give date of death
When (Month, day, year)
If spouse deceased, give date of death
When (Month, day, year)
When (Month, day, year)
Form SSA-1-BK (06-2018) UF
(a) How much were your total earnings last year?
19.
18. (a) Did you have wages or self-employment income covered under Social
Security in all years from 1978 through last year?
(b) List the years from 1978 through last year in which you did not have
wages or self-employment income covered under Social Security.
Enter below the names and addresses of all the persons, companies, or government agencies for whom you have worked
this year, last year, and the year before last. IF NONE, WRITE "NONE" BELOW AND GO ON TO ITEM 20.
Month Year Month Year
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
Work Ended
(If still working,
show "Not Ended")
20.
In what kind of trade or business were you self-employed?
(For example, storekeeper, farmer, physician)
(If "No," go
to item 22.)
NONE
21.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
Mar. Apr.
May Jul. Aug.
Sept. Oct. Nov. Dec.
Feb.Jan.
ALL
Jun.
(If you need more space, use "Remarks".)
(If "No," answer
item (b).)
(b) Check the year or years in
which you were self-
employed
(If "Yes," go
to item 19.)
Were your net earnings from
your trade or business $400 or
more? (Check "Yes" or "No")
(b) Place an "X" in each block for EACH MONTH of last year in which you did not
earn more than *$ in wages, and did not perform substantial
services in self-employment. These months are exempt months. If no months
were exempt months, place an "X" in "NONE". If all months were exempt months,
place an "X" in "ALL".
THIS ITEM MUST BE COMPLETED, EVEN IF YOU ARE AN EMPLOYEE.
(a) Were you self-employed this year and/or last year?
17.
• UNDER AGE 18
• AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL OR ELEMENTARY
SCHOOL FULL-TIME
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
(IF THERE ARE NO SUCH CHILDREN, WRITE "NONE" BELOW AND GO ON TO ITEM 18.)
Also list any student who is between the ages of 18 to 23 if such student was both: 1. Previously entitled to Social Security
benefits on any Social Security record for August 1981; and 2. In full-time attendance at a post-secondary school.
(If "Yes,"
answer (b).)
Page 4 of 9
List below FULL NAME OF ALL your children (including adopted children, and stepchildren) or dependent grandchildren
(including step grandchildren) who are now or were in the past 6 months UNMARRIED and:
NoYes
NoYes
NoYes
Yes No
This Year
Last Year
Amount $
(a) How much do you expect to earn next year?
25.
Answer this item ONLY if you are now in the last 4 months of your taxable year (Sept., Oct., Nov., and Dec., if your
taxable year is a calendar year).
If you use a fiscal year, that is, a taxable year that does not end December 31 (with income tax return due April 15), enter
here the month your fiscal year ends.
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
expect to earn more than *$ in wages, and do not expect to perform
substantial services in self-employment. These months will be exempt months.
If no months are expected to be exempt months, place an "X" in "NONE". If all
months are expected to be exempt months, place an "X" in "ALL".
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
(a) How much do you expect your total earnings to be this year?
(b) Place an "X" in each block for EACH MONTH of this year in which you did not or
will not earn more than *$ in wages, and did not or will not perform
substantial services in self-employment. These months are exempt months. If no
months are or will be exempt months, place an "X" in "NONE". If all months are or
will be exempt months, place an "X" in "ALL".
22.
DO NOT ANSWER ITEM 25 IF YOU ARE FULL RETIREMENT AGE AND 6 MONTHS OR OLDER. YOU MAY HAVE MORE
FILING OPTIONS; A SOCIAL SECURITY REPRESENTATIVE WILL CONTACT YOU TO DISCUSS ADDITIONAL
INFORMATION THAT MAY HELP YOU DECIDE WHEN TO START YOUR BENEFIT. GO TO ITEM 27.
23.
24.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8
AND ANSWER ONE OF THE FOLLOWING ITEMS:
NONE
Mar. Apr.
May Jul. Aug.
Sept.
Oct.
Nov. Dec.
Feb.Jan.
ALL
Jun.
NONE
Mar. Apr.
May Jul. Aug.
Sept. Oct. Nov. Dec.
Feb.Jan.
ALL
Jun.
(a) I want benefits beginning with the earliest possible month, and will accept an age-related reduction.
(b) I am full retirement age (or will be within 12 months), and want benefits beginning with the earliest possible month
providing there is no permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with .
Form SSA-1-BK (06-2018) UF Page 5 of 9
MEDICARE INFORMATION
If this claim is approved and you are still entitled to benefits at age 65, or you are within 3 months of age 65 or older you could
automatically receive Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you
live in Puerto Rico or a foreign country, you are not eligible for automatic enrollment in Medicare Part B, and you will need to
contact Social Security to request enrollment.
COMPLETE ITEM 26 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
Medicare Part B (Medical Insurance) helps cover doctor's services and outpatient care. It also covers some other services that
Medicare Part A does not cover, such as some of the services of physical and occupational therapists and some home health
care. If you enroll in Medicare Part B, you will have to pay a monthly premium. The amount of your premium will be determined
when your coverage begins. In some cases, your premium may be higher based on information about your income we receive
from the Internal Revenue Service. Your premiums will be deducted from any monthly Social Security, Railroad Retirement, or
Office of Personnel Management benefits you receive. If you do not receive any of these benefits, you will get a letter explaining
how to pay your premiums. You will also get a letter if there is any change in the amount of your premium.
If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have
Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but did not
sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to March 31) to enroll in Part B, and
coverage will start July 1 of that year.
You can also enroll in a Medicare prescription drug plan (Part D). To learn more about the Medicare prescription drug plans and
when you can enroll, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Medicare can
also tell you about agencies in your area that can help you choose your prescription drug coverage. The amount of your premium
varies based on the prescription drug plan provider. The amount you pay for Part D coverage may be higher than the listed plan
premium, based on information about your income we receive from the Internal Revenue Service.
If you have limited income and resources, we encourage you to apply for the Extra Help that is available to assist you with
Medicare prescription drug costs. The Extra Help can pay the monthly premiums, annual deductibles, and prescription co-
payments. To learn more or apply, please visit www.socialsecurity.gov, call 1-800-772-1213 (TTY 1-800-325-0778) or visit the
nearest Social Security office.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Affects Your Benefits".
Amount $
Amount $
(Month)
Form SSA-1-BK (06-2018) UF
Do you want to enroll in Medicare Part B (Medical insurance)?
If you are within 2 months of age 65 or older, blind or disabled,
do you want to file for Supplemental Security Income?
26.
27.
Page 6 of 9
REMARKS (You may use this space for any explanations. If you need more space, attach a separate sheet.)
NoYes
NoYes
Form SSA-1-BK (06-2018) UF Page 7 of 9
1. Signature of Witness
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two witnesses who
know the applicant must sign below, giving their full addresses. Also, print the applicant's name in the Signature block.
SIGNATURE OF APPLICANT
County (if any) in which you now live
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink.)
Telephone number(s) at which you may be contacted during the day
Address (Number and Street, City, State and ZIP Code)
Direct Deposit Payment Information (Financial Institution)
Routing Transit Number
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.
Date (Month, day, year)
Account Number
Savings
Checking
Direct Deposit Refused
Enroll in Direct Express
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
Form SSA-1-BK (06-2018) UF Page 8 of 9
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 on page 8.
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
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY RETIREMENT INSURANCE BENEFITS
Your application for Social Security 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
TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT
DATE CLAIM RECEIVED
SOCIAL SECURITY CLAIM NUMBER
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 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 us from making an accurate and
timely decision concerning your or a dependent’s eligibility to benefit payments.
We will use the information you provide to help us determine your or a dependent’s eligibility for benefit payments. We may also
share the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA)
in the efficient administration of its programs.
2. To student volunteers, individuals working under a personal services contract, and other workers who technically do not have
the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access to
personally identifiable information in SSA records in order to perform their assigned agency functions.
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 (SORN) 60-0059, entitled Earnings
Recording and Self-Employment Income System and 60-0089, entitled Claims Folders System. Additional information and a full
listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
- 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 11 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.
Paperwork Reduction Act Statement
AFTER YOU RECEIVE A
NOTICE FOF AWARD
BEFORE YOU RECEIVE A
NOTICE OF AWARD
SSA OFFICE
Form SSA-1-BK (06-2018) UF Page 9 of 9
You (are) (are not) earning wages of more than
$ a month.
You (are) (are not) self-employed rendering
substantial services in your trade or business.
CHANGES TO BE REPORTED AND HOW TO REPORT
Failure to report may result in overpayments that must be repaid, and in possible monetary penalties
If you are under full retirement age, retirement benefits cannot be payable to you for any month before the month in which you
file your claim.
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.)
Any beneficiary dies or becomes unable to handle benefits.
Work Changes - On your application you told us you expect
total earnings for to be $ .
(Report AT ONCE if this work pattern changes)
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.
For those under full retirement age, the law requires that a
report of earnings be filed with SSA within 3 months and 15
days after the end of any taxable year in which you earn more
than the annual exempt amount. You may contact SSA to file a
report. Otherwise, SSA will use the earnings reported by your
employer(s) and your self-employment tax return (if applicable)
as the report of earnings required by law, to adjust benefits
under the earnings test. It is your responsibility to ensure that
the information you give concerning your earnings is correct.
You must furnish additional information as needed when your
benefit adjustment is not correct based on the earnings on
your record.
HOW TO REPORT
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU ANSWER QUESTION 26.
You go outside the U.S.A. for 30 consecutive days
or longer.
Your citizenship or immigration status changes.
(Year)
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 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.
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.
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.
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 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.
•
•
•
Delayed retirement credits may be added to your benefits if you request them to start when you are full retirement
age or older.
•
Please visit our www.ssa.gov web site to use the Retirement Estimator to get a personal estimate of how much your
benefits will be at different ages. In addition, our web site provides information about other things you should think about
when you make your decision about when to begin your benefits.
•
If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not actually
receive your full benefit amount for one or more months before full retirement age because benefits are withheld due to your
earnings, your benefit will be increased at full retirement age to give credit for this withholding. Thus, your benefit amount at
full retirement age will be reduced only if you receive one or more full benefit payments prior to the month you attain full
retirement age.
If you are over full retirement age, retirement benefits may be payable to you for some months before the month in which you
file this claim.
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Ssa-1-bk Application For Retirement Insurance Benefits

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Completed 18 November 2019

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