• 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.

  • Check (✔) whether you are:*
  • Is English your preferred language to speak and write?*
  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Was a public record of your birth made before you were age 5?*
  • Was a religious record of your birth made before you were age 5?*
  • Are you a U.S. citizen?*
  • Are you an alien lawfully present in the U.S.?*
  • When were you lawfully admitted to the U.S.?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you used any other names?*
  • Have you used any other Social Security number(s)?*
  • When do you believe your condition(s) became severe enough to keep you from working (even if you have never worked)?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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?*
  • 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?*
  • 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.)*
  • Did you or your spouse (or prior spouse) work in the railroad industry for 5 years or more?*
  • Do you have Social Security credits (for example, based on work or residence) under another country's Social Security System?*
  • 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?*
  • Have you ever been married?*
  • Are you Currently Married?*
  • When?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marriage performed by:*
  • Spouse's date of birth:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Do you have another spouse where the marriage: 

    • Lasted at least 10 years
    • Had a marriage that ended in 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
  • *
  • When?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • When?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marriage performed by:*
  • Spouse's date of birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spouse's date of death: (if applicable)
     - -
    2 digit month, 2 digit day, 4 digit year

  • Have you had a marriage where 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
  • *
  • When?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of divorce:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marriage performed by:*
  • Spouse's date of birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spouse's date of death: (if applicable)
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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)
  • Did you have wages or self-employment income covered under Social Security in all years from 1978 through last year?*

  • 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 CONTINUE

  • Work Began

  • Work Ended (If still working show "Not Ended")

  • Do you have another employer, for whom you worked this year or last year, to enter?*

  • Work Began

  • Work Ended (If still working show "Not Ended")

  • Do you have another employer, for whom you worked this year or last year, to enter?*

  • Work Began

  • Work Ended (If still working show "Not Ended")

  • Were you self-employed this year or last year?*
  • Check the year (or years) you were self-employed.*
  • Were your net earnings from the trade or business $400 or more?*
  • Are you still unable to work because of your illnesses, injuries, or conditions?*
  • Enter the date you became able to work.*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are your illnesses, injuries, or conditions related to your work in any way?*
  • Are you blind or do you have low vision even with glasses or contacts?*
  • Have you filed, or do you intend to file, for any other public disability benefits (including workers' compensation, Black Lung benefits and SSI)?*
  • The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply):*
  • Did you receive any money from an employer(s) on or after the date you indicated when you became unable to work because of your illness, injuries, or conditions? If "Yes" give the amount and explain.*
  • Do you expect to receive any additional money from an employer, such as sick pay, vacation pay, other special pay? If "Yes," please give amounts and explain.*
  • 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 had no earnings?*
  • Do you have a dependent parent who was receiving at least one-half support from you when you became unable to work because of your disability?*
  • 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 retirement or disability benefits or who is deceased?*
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -

  • Direct Deposit Payment Information (Financial Institution)

  • Account type:*
  • Enroll in Direct Express?*
  • Is your mailing address different from your residential address?*
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  • Should be Empty: