Form SSA-3369-BK "Work History Report"

Form SSA-3369-BK Instructions

The information you provide via this form is used to make a decision on your disability request. Follow all the instructions to prevent protracting your disability claim decision:

• Answer all the questions on the form;
• If you do not know or do not remember something, feel free to enter "do not know" or "do not remember";
• Print or type all your answers neatly;
• Make sure you have provided the necessary explanations for all the questions that required them;
• If the full answer to any question requires more space, continue in the "Remark" section;
• Do not forget to indicate the number of the question you answer if you continue explanations in the "Remark" section.

You can find detailed SSA Form 3369-BK instructions on the first two pages of the form. Read them carefully, detach, and keep for references. If you need help when completing the form, fill out as much as you can and call a phone number sent you with the form. You can also ask your lawyer or attorney to help you.

How to Fill out SSA-3369-BK?

1. Section 1. Information about the Disabled Person. Provide your name, Social Security number, and daytime phone number. If you do not have a phone, indicate any number where the SSA can leave a message for you if needed;
2. Section 2. Information about Your Work. List all the jobs you have had in the past 15 years in chronological order. Start with the most recent job. Try to be as specific as possible regarding the month, date, and year of the beginning and end of your job. Give detailed information about your duties on each job you listed on the next six pages. The boxes on these pages are self-explanatory and designated to help you to enter all information the SSA may need to make the decision on your claim;
3. Section 3. Remarks. Use it if the space provided in any of the previous boxes was not enough, or if you want to explain your answers. If you are not the person who has requested the disability benefits, print your name in the appropriate box under the "Remarks" section;
4. Specify the date, mailing address, and email address (if applicable).

Return the filled-out Form SSA-3369-BK to the state agency that requested it. If you cannot find the envelope with your state agency address, call the SSA at the phone number indicated on the second page of the form.