Form SSA-1-BK Application for Retirement Insurance Benefits

Form SSA-1-BK is a U.S. Social Security Administration form also known as the "Application For Retirement Insurance Benefits". The latest edition of the form was released in June 1, 2018 and is available for digital filing.

Download a PDF version of the Form SSA-1-BK down below or find it on U.S. Social Security Administration Forms website.

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Form SSA-1-BK (06-2018) UF
Page 1 of 9
Discontinue Prior Editions
TEL
OMB No. 0960-0618
Social Security Administration
(Do not write in this space)
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.
FIRST NAME, MIDDLE INITIAL, LAST NAME
1.
(a) PRINT your name
(b) Check (X) whether you are
Male
Female
2.
Enter your Social Security number
Answer question 3 if English is not your language preference. Otherwise, go to item 4.
3.
Enter the language you prefer to:
Speak
Write
Month, Day, Year
4.
(a) Enter your date of birth
(b) Enter name of city and state, or foreign country where
you were born.
Yes
No
Unknown
(c) Was a public record of your birth made before you were age 5?
(d) Was a religious record of your birth made before you were age 5?
Yes
No
Unknown
5.
(a) Are you a U.S. citizen?
Yes
No
(Go to item 7.)
(Go to item (b).)
(b) Are you an alien lawfully present in U.S.?
Yes
No
(Go to item (c))
(Go to item 6)
(c) When were you lawfully admitted to the U.S.?
6.
Enter your full name at birth if different from
FIRST NAME, MIDDLE INITIAL, LAST NAME
item 1(a)
7.
(a) Have you used any other name(s)?
Yes
No
(Go to item (b).)
(Go to item 8.)
(b) Other names(s) used.
8. (a) Have you used any other Social Security number(s)?
Yes
No
(Go to item (b))
(Go to item 9.)
(b) Enter Social Security number(s) used.
(Over)
Form SSA-1-BK (06-2018) UF
Page 1 of 9
Discontinue Prior Editions
TEL
OMB No. 0960-0618
Social Security Administration
(Do not write in this space)
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.
FIRST NAME, MIDDLE INITIAL, LAST NAME
1.
(a) PRINT your name
(b) Check (X) whether you are
Male
Female
2.
Enter your Social Security number
Answer question 3 if English is not your language preference. Otherwise, go to item 4.
3.
Enter the language you prefer to:
Speak
Write
Month, Day, Year
4.
(a) Enter your date of birth
(b) Enter name of city and state, or foreign country where
you were born.
Yes
No
Unknown
(c) Was a public record of your birth made before you were age 5?
(d) Was a religious record of your birth made before you were age 5?
Yes
No
Unknown
5.
(a) Are you a U.S. citizen?
Yes
No
(Go to item 7.)
(Go to item (b).)
(b) Are you an alien lawfully present in U.S.?
Yes
No
(Go to item (c))
(Go to item 6)
(c) When were you lawfully admitted to the U.S.?
6.
Enter your full name at birth if different from
FIRST NAME, MIDDLE INITIAL, LAST NAME
item 1(a)
7.
(a) Have you used any other name(s)?
Yes
No
(Go to item (b).)
(Go to item 8.)
(b) Other names(s) used.
8. (a) Have you used any other Social Security number(s)?
Yes
No
(Go to item (b))
(Go to item 9.)
(b) Enter Social Security number(s) used.
(Over)
Form SSA-1-BK (06-2018) UF
Page 2 of 9
Do not answer question 9 if you are one year past full retirement age or older; go to question 10.
9.
(a) Are you, or during the past 14 months have you been,
Yes
No
unable to work because of illnesses, injuries or conditions?
(b) If "Yes", enter the date you became unable to work.
MONTH, DAY, YEAR
10.
(a) Have you (or has someone on your behalf) ever filed an
Yes
No
Unknown
application for Social Security, Supplemental Security
(If "No," go
(If "Yes,"
(If "Unknown,"
Income, or hospital or medical insurance under Medicare?
to item 11.)
answer (b)
go to item 11.)
and (c).)
(b) Enter name of person(s) on whose Social Security record
FIRST NAME, MIDDLE INITIAL, LAST NAME
you filed other application.
(c) Enter Social Security number(s) of person named in (b).
(If unknown, so indicate.)
Yes
No
11.
(a) Were you in the active military or naval service (including
Reserve or National Guard active duty or active duty for
(If "Yes," answer
(If "No," go
training) after September 7, 1939 and before 1968?
(b) and (c).)
to item 12.)
Month, Year
Month, Year
(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
Yes
No
Administration benefits only if you waived Military retirement pay).
Did you or your spouse (or prior spouse) work in the railroad industry
12.
Yes
No
for 5 years or more?
13.
(a) Do you (or your spouse) have Social Security credits (for example
Yes
No
based on work or residence) under another country's Social
(If "No," go
(If "Yes,"
Security system?
answer (b)
to item 14.)
and (c).)
(b) List the country(ies):
(c) Are you (or your spouse) filing for foreign Social Security benefits?
Yes
No
Answer question 14 only if you were born January 2, 1924, or later. Otherwise go on to question 15.
(a) Are you entitled to, or do you expect to be entitled to, a pension or
14.
Yes
No
annuity (or a lump sum in place of a pension or annuity) based on your
(If "Yes,"
(If "No," go on
work after 1956 not covered by Social Security?
answer (b)
to item 15.)
and (c).)
MONTH
YEAR
(b) I became entitled, or expect to become entitled, beginning
MONTH
YEAR
(c) 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, an annuity, or a lump sum payment based on my employment not
covered by Social Security, or if such pension or annuity stops.
Form SSA-1-BK (06-2018) UF
Page 3 of 9
Yes
No
15.
Have you been married?
(If "Yes," answer item 16.)
(If "No," go to item 17.)
16.
(a) Give the following information about your current marriage. If not currently married, write "None"
Go on to item 16(b).
Spouse's name (including maiden name)
When (Month, day, year)
Where (Name of City and State)
When (Month, day, year)
Where (Name of City and State)
How marriage ended (If still in effect, write
"Not Ended.")
Marriage performed by:
Spouse's date of birth (or age)
If spouse deceased, give date of death
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)
(b) 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 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.
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 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 birth (or age)
If spouse deceased, give date of death
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)
(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."
To whom married
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 birth (or age)
If spouse deceased, give date of death
Clergyman or public official
Other (Explain in "Remarks")
Spouse's Social Security number (If none or unknown, so indicate)
Use the 'Remarks' space on page 6 for marriage continuation or explanation.
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.
(Turn to Page 4)
Form SSA-1-BK (06-2018) UF
Page 4 of 9
17.
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:
• AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL OR ELEMENTARY
• UNDER AGE 18
SCHOOL FULL-TIME
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
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 THERE ARE NO SUCH CHILDREN, WRITE "NONE" BELOW AND GO ON TO ITEM 18.)
18. (a) Did you have wages or self-employment income covered under Social
Yes
No
Security in all years from 1978 through last year?
(If "Yes," go
(If "No," answer
to item 19.)
item (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.
19.
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.
Work Ended
NAME AND ADDRESS OF EMPLOYER
Work Began
(If still working,
(If you had more than one employer, please list them in order beginning with your
show "Not Ended")
last (most recent) employer.)
Month
Year
Month
Year
(If you need more space, use "Remarks".)
THIS ITEM MUST BE COMPLETED, EVEN IF YOU ARE AN EMPLOYEE.
Yes
No
20.
(a) Were you self-employed this year and/or last year?
(If "Yes,"
(If "No," go
answer (b).)
to item 22.)
(b) Check the year or years in
Were your net earnings from
In what kind of trade or business were you self-employed?
which you were self-
your trade or business $400 or
(For example, storekeeper, farmer, physician)
employed
more? (Check "Yes" or "No")
This Year
Yes
No
Last Year
Yes
No
21.
Amount $
(a) How much were your total earnings last year?
(b) Place an "X" in each block for EACH MONTH of last year in which you did not
NONE
ALL
earn more than *$
in wages, and did not perform substantial
services in self-employment. These months are exempt months. If no months
Jan.
Feb.
Mar.
Apr.
were exempt months, place an "X" in "NONE". If all months were exempt months,
place an "X" in "ALL".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Sept.
Oct.
Nov.
Dec.
Affects Your Benefits".
Form SSA-1-BK (06-2018) UF
Page 5 of 9
(a) How much do you expect your total earnings to be this year?
Amount $
22.
(b) Place an "X" in each block for EACH MONTH of this year in which you did not or
NONE
ALL
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
Jan.
Feb.
Mar.
Apr.
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".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Sept.
Nov.
Dec.
Oct.
Affects Your Benefits".
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).
23.
(a) How much do you expect to earn next year?
Amount $
(b) Place an "X" in each block for EACH MONTH of next year in which you do not
NONE
ALL
expect to earn more than *$
in wages, and do not expect to perform
substantial services in self-employment. These months will be exempt months.
Jan.
Feb.
Mar.
Apr.
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".
May
Jun.
Jul.
Aug.
*Enter the appropriate monthly limit after reading the instructions, "How Work
Sept.
Oct.
Nov.
Dec.
Affects Your Benefits".
24.
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.
(Month)
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.
PLEASE READ CAREFULLY THE INFORMATION ON THE BOTTOM OF PAGE 8
AND ANSWER ONE OF THE FOLLOWING ITEMS:
(a)
I want benefits beginning with the earliest possible month, and will accept an age-related reduction.
25.
(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
.
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.

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