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Get SSA-16-BK 2018-2024

If unknown check this block. Form SSA-16-BK 01-2015 ef 01-2015 Page 1 Destroy prior editions b and c go to item 11 b 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 Enter dates of service FROM 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. 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. Send only comments relating to our time estimate to this address not the completed form. Page 6 RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS SSA OFFICE Person to Contact About Your Claim Date Claim Received Your application for Social Security disability benefits has been received and will be processed as quickly as possible. TEL SOCIAL SECURITY ADMINISTRATION TOE 120/145 APPLICATION FOR DISABILITY INSURANCE BENEFITS Form Approved OMB No* 0960-0618 Do not write in this space 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 FIRST NAME MIDDLE INITIAL LAST NAME 2. Enter your Social Security Number 3. Check X whether you are Female Male 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 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* 6. a Are you a U*S* citizen b Are you an alien lawfully present in the U*S* If Yes go to item 7 If No answer b If Yes answer c If No go to item 8 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 c Other name s used* 8. a Have you used any other Social Security number s b Enter Social Security number s used* When do you believe your condition s became severe enough to keep you from working even if you have never worked 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 b Enter name of person on whose Social Security record you filed the other application* in b. 12. Did you or your spouse or prior spouse work in the railroad industry for 5 years or more 13. a Do you have Social Security credits for example based on work or residence under another country s Social Security System b List the country ies 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 If No go to item 12 I became entitled or expect to become entitled beginning MONTH YEAR I became eligible or expect to become eligible beginning 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.

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