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SSA-16. Form SSA-16 (11-2022) UF Discontinue Prior Editions Social Security Administration. Page 1 of 7. OMB No. 0960-0618. APPLICATION FOR DISABILITY INSURANCE BENEFITS. (Do not write in this space) (Do not write in this space) apply for a period of disability and/or all insurance benefits for which I am eligible under Title II and Part A of ...
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- Information About You
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Your date and place of birth and Social Security number.The name, Social Security number, and date of birth or age of your current spouse and any former spouse. You should also know the dates and places of marriage and dates of divorce or death (if appr...Names and dates of birth of children not yet 18 years of age.Your bank or other financial institution's Routing Transit Numberand the account number.Name, address, and phone number of someone we can contact who knows about your medical conditions and can help with your application.Detailed information about your medical illnesses, injuries, or conditions:The amount of money earned last year and this year.The name and address of your employer(s) for this year and last year.The beginning and ending dates of any active U.S. military service you had before 1968.A list of the jobs (up to five) that you had in the 15 years before you became unable to work and the dates you worked at those jobs.Learn about the disability benefits programs, the application process, and the documents you need to provide. You can apply online, by phone, or in person, and check the status of your application online or by phone.
May 10, 2023 · The disability forms involved in a typical application for Social Security benefits are: SSA-16-BK, Application for Disability Insurance Benefits ( SSDI only) SSA-8000-BK, Application for Supplemental Security Income ( SSI only) SSA-3368-BK, Adult Disability Report. SSA-3369-BK, Work History Report.
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