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7Form SSA-16 (06-2018) UF
Page 1 of 7
Discontinue prior editions
OMB No. 0960-0618
Social Security Administration
(Do not write in this space)
APPLICATION FOR DISABILITY INSURANCE BENEFITS
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
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
Yes
No
Unknown
age 5?
6.
Yes
No
(a) Are you a U.S. citizen?
(If "No," answer (b))
(If "Yes," go to item 7)
Yes
No
(b) Are you an alien lawfully present in the U.S.?
(If "No," go to item 7)
(If "Yes," answer (c))
(c) When were you lawfully admitted to the U.S.?
7.
(a) Enter your name at birth if different from item (1)
Yes
No
(b) Have you used any other names?
(If "No," go to item 8)
(If "Yes," answer (c))
(c) Other name(s) used.
8.
Yes
No
(a) Have you used any other Social Security number(s)?
(If "No" go to item 9)
(If "Yes," answer (b))
(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
Yes
No
Unknown
application for Social Security benefits, a period of disability
(If "Yes," answer
(If "No," or "Unknown,"
under Social Security, Supplemental Security Income, or
(b) and (c))
go to item 11)
hospital or medical insurance under Medicare?
(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 (06-2018) UF
Page 1 of 7
Discontinue prior editions
OMB No. 0960-0618
Social Security Administration
(Do not write in this space)
APPLICATION FOR DISABILITY INSURANCE BENEFITS
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
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
Yes
No
Unknown
age 5?
6.
Yes
No
(a) Are you a U.S. citizen?
(If "No," answer (b))
(If "Yes," go to item 7)
Yes
No
(b) Are you an alien lawfully present in the U.S.?
(If "No," go to item 7)
(If "Yes," answer (c))
(c) When were you lawfully admitted to the U.S.?
7.
(a) Enter your name at birth if different from item (1)
Yes
No
(b) Have you used any other names?
(If "No," go to item 8)
(If "Yes," answer (c))
(c) Other name(s) used.
8.
Yes
No
(a) Have you used any other Social Security number(s)?
(If "No" go to item 9)
(If "Yes," answer (b))
(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
Yes
No
Unknown
application for Social Security benefits, a period of disability
(If "Yes," answer
(If "No," or "Unknown,"
under Social Security, Supplemental Security Income, or
(b) and (c))
go to item 11)
hospital or medical insurance under Medicare?
(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
Page 2 of 7
Form SSA-16 (06-2018) UF
11. (a) Were you in the active military or naval service (including
Yes
No
Reserve or National Guard active duty or active duty for training)
(If "Yes," answer
(If "No," go to
after September 7, 1939 and before 1968?
(b) and (c))
item 12)
FROM: (Month, Year)
TO: (Month, Year)
(b) Enter dates of service
(c) Have you ever been (or will you be) eligible for a monthly
benefit from a military or civilian Federal agency? (Include
Yes
No
Veteran's Administration benefits only if you waived military
retirement pay.)
12. Did you or your spouse (or prior spouse) work in the railroad
Yes
No
industry for 5 years or more?
13. (a) Do you have Social Security credits (for example, based on work
Yes
No
or residence) under another country's Social Security System?
(If "Yes," answer (b))
(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
Yes
No
or annuity (or a lump sum in place of a pension or annuity) based
(If "No," go to item 15)
(If "Yes," answer
on your work after 1956 not covered by Social Security?
(b) and (c))
(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.
Yes
No
(a) Have you ever been married?
(If "No," go to item 16)
(If "Yes," answer (b))
(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:
Spouse's date of birth (or age)
Spouse's Social Security Number
(If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
(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:
Spouse's date of
Date of spouse's death
Spouse's Social Security Number
birth (or age)
(If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
Page 3 of 7
Form SSA-16 (06-2018) UF
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:
Spouse's date of birth
Date of spouse's death
Spouse's Social Security Number
(or age)
(If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
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
Yes
No
Social Security in all years from 1978 through last year?
(If "Yes," go to item 18)
(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.
Work Ended (If still
NAME AND ADDRESS OF EMPLOYER
Work Began
working show
(If you had more than one employer, please list them
"Not Ended")
in order beginning with your last (most recent) employer)
MONTH
YEAR
MONTH
YEAR
(If you need more space, use "Remarks".)
Form SSA-16 (06-2018) UF
Page 4 of 7
19. Complete item 19 even if you were an employee.
Yes
No
(a) Were you self-employed this year or last year?
(If "Yes," answer (b))
(If "No," go to item 20)
(b) Check the year (or
In what type of trade/business
Were your net earnings from the
years) you were
were you self-employed?
trade or business $400 or more?
self-employed
(For example, storekeeper, farmer,
(Check "Yes" or "No")
physician)
This year
Last year
Yes
No
20. (a) How much were your total earnings last year?
Count both wage and self-employment income.
Amount $
(If none, write "None.")
(b) How much have you earned so far this year?
(If none, write "None.")
Amount $
21. (a) Are you still unable to work because of your illnesses, injuries,
Yes
No
or conditions?
(If "Yes," go to item 22)
(If "No," answer (b))
MONTH, DAY, YEAR
(b)
Enter the date you became able to work.
22. Are your illnesses, injuries, or conditions related to your work in
Yes
No
any way?
23. Are you blind or do you have low vision even with glasses or
Yes
No
contacts?
24.
(a) Have you filed, or do you intend to file, for any other public
Yes
No
disability benefits (including workers' compensation, Black Lung
(If "Yes," answer (b))
(If "No," to item 25)
benefits and SSI)?
(b) The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply):
Welfare
Veterans Administration Benefits
Supplemental Security Income
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
Yes
No
date in item 9 when you became unable to work because of your
illnesses, injuries, or conditions? If "Yes", give the amounts and
Amount $
explain in "Remarks".
(b) Do you expect to receive any additional money from an
Yes
No
employer, such as sick pay, vacation pay, other special pay? If
"Yes," please give amounts and explain in "Remarks".
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
Yes
No
had no earnings?
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
Yes
No
your disability? If "Yes," enter the parent's name and address and
Social Security number, if known, in "Remarks".
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
Yes
No
Unknown
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").
Form SSA-16 (06-2018) 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.
Date (Month, Day, Year)
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
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
Enroll in Direct Express
Savings
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
2. Signature of Witness
Address (Number and street, City, State and ZIP Code)
Address (Number and street, City, State and ZIP Code)
