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Get SSA-1-BK 2019-2021

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. Form SSA-1-BK 06-2018 UF Discontinue Prior Editions Social Security Administration Page 1 of 9 OMB No. 0960-0618 TEL APPLICATION FOR RETIREMENT INSURANCE BENEFITS Do not write in this space 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. 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. CHANGES TO BE REPORTED AND HOW TO REPORT Failure to report may result in overpayments that must be repaid and in possible monetary penalties You change your mailing address for checks or residence. 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* a PRINT your name FIRST NAME MIDDLE INITIAL LAST NAME b Check X whether you are Male Female Enter your Social Security number Answer question 3 if English is not your language preference. Otherwise go to item 4. Enter the language you prefer to Speak a Enter your date of birth Write Month Day Year 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 a Are you a U*S* citizen b Are you an alien lawfully present in U*S* Go to item 7. c When were you lawfully admitted to the U*S* Enter your full name at birth if different from item 1 a a Have you used any other name s b Other names s used* b Enter Social Security number s used* Over Do not answer question 9 if you are one year past full retirement age or older go to question 10. a Are you or during the past 14 months have you been unable to work because of illnesses injuries or conditions b If Yes enter the date you became unable to work. 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 b Enter name of person s on whose Social Security record you filed other application* MONTH DAY YEAR If No go If Yes to item 11. answer b and c. If unknown so indicate. If Yes answer 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 b Enter date s of service From To 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..

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