TEL TOE 120/145/155
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0618
(D o not writ e in t hi s sp ace)
APPLICATION FOR RETIREMENT INSURANCE BENEFITS
I apply for all insurance benefits for which I am el igi ble 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 p resently 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.
(a) PRINT your name
FIRST NAME, MIDDLE INITIAL, LAST NAME
1.
Male Female
(b) Check (X) whether you are
- -
Enter your Social Security number
2.
3.
If this claim is awarded, do you want a password to use SSA’s Internet/phone service?
Yes No
Answer question 4 if English is not your language preference. Otherwise, go to item 5.
Write
4.
Enter the language you prefer to:
Speak
Month, Day, Year
5.
(a) Enter your date of birth
(b) Enter name of 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 age 5?
Yes No Unknown
6.
(a) Are you a U.S. citizen?
Yes No
(Go to
(Go to
item 8.)
item (b).)
(b) Are you an alien lawfully present in U.S.?
No
Yes
7.
FIRST NAME, MIDDLE INITIAL, LAST NAME
Enter your full name at birth
if different from item 1(a)
8.
Yes
No
(Go to
(Go to
(a) Have you used any other name(s)?
item (b).)
item 9.)
(b) Other names(s) used.
9.
Yes No
(a) Have you used any other Social Security number(s)?
(Go to
(Go to
item (b))
item 10.)
(b) Enter Social Security number(s) used.
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Do not answer question 10 if you are one year past full retirement age or older; go to question 11.
10.
(a) Are you, or during the past 14 months have you been, unable
Yes No
to work because of illnesses, injuries or conditions?
MONTH, DAY, YEAR
(b) If “Yes”, enter the date you became unable to work.
11.
(a) Have you (or has someone on your behalf) ever filed an application
Yes No Unknown
for Social Security, Supplemental Security Income, or hospital or
(If “Unknown,”
(If “Yes,” answer
(If “No,” go
medical insurance under Medicare?
go to item 12.)
(b) and (c).)
to item 12.)
FIRST NAME, MIDDLE INITIAL, LAST NAME
(b) Enter name of person(s) on whose Social Security record
you filed other application.
(c) Enter Social Security number(s) of person named in (b).
(If unknown, so indicate.)
–
If you are now AGE 62 or older, or you will be AGE 62 in this month or one of the next 4
months, answer question 12. Otherwise, go to question 13.
Yes No
12.
(a) Were you in the active military or naval service (including
Reserve or National Guard active duty or active duty
(If “Yes,” answer
(If “No,” go
(b) an d (c).)
to item 13.)
for training) after September 7, 1939 and before 1968?
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? (including
Yes
No
Veterans Administration benefits only if you waived
Military retirement pay)
13.
Did you or your spo use (or prior spouse ) work in the railroad
Yes
No
industry for 5 years or more?
Yes No
14.
(a) Do you (or your spouse) have Social Security credits (for example
based on work or residence) under another country’s Social
(If “No,” go to
(If “Yes,” answer
Security system?
item 15.)
(b) and (c).)
(b) List the country(ies):
Yes No
(c) Are you (or your spouse) filing for foreign Social Security benefits?
Answer question 15 only if you were born January 2, 1924, or later. Otherwise go on to question 16.
15.
(a) Are you entitled to, or do you expect to be entitled to, a pension or
Yes
No
annuity based on your work after 1956 not covered by Social
(If “Yes,” answer
(If “No,” go on
Security ?
(b) and (c).)
to item 16.)
MONTH
YEAR
(b)
I became entitled, or expect to become entitled, beginning
MONTH
YEAR
(c)
I became eligible, or expect to become eligible, beginning
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Yes
No
16. Have you been married?
(If “Yes,” answer
(If “No,” go to
item 17.)
item 18.)
17. (a) Give the following information about your current marriage. If not currently married, show your last marriage here:
When (Month, day, year)
To whom married
Where (Name of City and State)
When (Month, day, year)
How marriage ended (If still in effect,
Where (Name of City and State)
write “Not Ended.”)
Current
If spouse dec eased, give date of death
Marriage performed by:
Spouse’s date of birth (or age)
or last
Clergyman or public official
marriage
Other (Explain in Remarks)
Spouse’s Social Security Number (If none or unknown, so indicate)
(b) Give the following information about each of your previous marriages. (IF NONE, WRITE “NONE”)
When (Month, day, year)
To whom married
Where (Name of City and State)
When (Month, day, year)
How marriage ended
Where (Name of City and State)
Your
previous
marriage
If spouse deceased, give date of death
Marriage performed by:
(Use a separate
Spouse’s date of birth (or age)
statement for
Clergyman or public official
information
Other (Explain in Remarks)
about any
other
marriages.)
Spouse’s Social Security Number (If none or unknown, so indicate)
List below FULL NAME OF ALL your children (including natural children, adopted children, and stepchildren) or
18.
dependent grandchildren (including stepgrandchildren) who are now or were in the past 6 months UNMARRIED and:
•
•
UNDER AGE 18
AGE 18 TO 19 AND ATTENDING SECONDARY SCHOOL
•
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 prior to May 1982.
(IF THERE ARE NO SUCH CHILDREN, WRITE “NONE” BELOW AND GO ONTO ITEM 19.)
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19.
Yes
No
(a) Did you have wages or self-employment income covered under Social
(If “Yes,” go to
(If “No,” answer
Security in
all
years from 1978 through last year?
item 20.)
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.
(a) Enter below the names and addresses of all the persons, companies, or government agencies for whom you
20.
have worked this year, last year, and the year before last.
IF NONE, WRITE “NONE” BELOW AND GO ON TO
ITEM 21.
WorkEnded(Ifstill
NAME AND ADDRESS OF EMPLOYER
Work Began
working,
(If you had more than one employer, please list them
show “Not Ended”)
in order beginning with your last (most recent) employer.)
Month Year Month Year
(If you need more space, use “Remarks”.)
(b) Are you an officer of a corporation, or are you related to an officer of a
Yes No
corporation?
21. May we ask your employers for wage information needed to process your
Yes No
claim?
THIS ITEM MUST BE COMPLETED, EVEN IF YOU ARE AN EMPLOYEE.
22.
Yes No
(a) Were you self-employed this year and/or last year?
(If “Yes,”
(If “No,”
go to item 23.)
answer (b).)
(b)
Check the year or
Were your net earnings from your
In what kind of trade or business were you self-employed?
years in which you
trade or business $400 or more?
(For example, storekeeper, farmer, physician)
were self-employed
(Check “Yes” or “No”)
This year
Yes
No
Last year
Yes No
23.
Amount
$
(a) How much were your total earnings last year?
(b)
NONE
ALL
Place an “X” in each block for EACH MONTH of last year in which you did not earn
more than *$ in wages, and did not perform substantial services in
self-employment. These months are exempt months. If no months were exempt
Jan.
Feb.
Mar. Apr.
months, place an “X” in “NONE”. If all months were exempt months, place an “X” in
“ALL”.
May Jul. Aug.
Jun.
*Enter the appropriate monthly limit after reading the instructions, “How Your
Sept. Oct. Nov. Dec.
Earnings Affect Your Benefits”.
24.
Amount
$
(a) How much do you expect your total earnings to be this year?
(b)
Place an “X” in each block for EACH MONTH of this year in which you did not or will
NONE ALL
not earn more than *$ in wa ges, and d id not or will no t pe rform
substantial services in self-employment. These months are exempt months. If no
months are or will be exempt months, place an “X” in “NONE”. If all months are or
Jan. Feb. Apr.
Mar.
willbeexemptmonths,placean”X”in”ALL”.
May Jun. Jul. Aug.
*Enter the appropriate monthly limit after reading the instructions, “How Your
Earnings Affect Your Benefits”.
Sept. Nov. Dec.
Oct.
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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 isacalendar year).
$
25.
(a) How much do you expect to earn next year?
Amount
(b) Place an “X” in each block for EACH MONTH of n ext year in which yo u 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. If
Jan. Feb. Mar. Apr.
no months are expected to be exempt months, place an “X” in “NONE”. If all
monthsareexpectedtobeexemptmonths,placean”X”in”ALL”.
May Jun. Jul. Aug.
*Enter the appropriate monthly limit after reading the instructions, “How Your
Earnings Affect Your Benefits”.
Sept. Oct. Nov. Dec.
26.
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 27 IF YOU ARE FULL RETIREMENT AGE AND 6 MONTHS OR OLDER; GO TO ITEM 28.
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 that will be the most
27.
advantageous.
(b) I am full retirement age (or will be within 4 months) and I want benefits beginning with
the earliest possible month that will be the most advantageous providing there is no
permanent reduction in my ongoing monthly benefits.
(c) I want benefits beginning with . I understand that either a hi gh er initia l payment or a higher
continuing monthly benefit amount may be possible, but I choose not to take it.
MEDICARE INFORMATION
If this claim is approved and you are still e ntitl ed to benefits at age 65, you will automatically receive Medicare Part A (Hospital
Insurance) and Medicare Part B (Medical Insurance) coverage at age 65. If you are not eligible for automatic enrollment in Medicare
Part B, this application may be used for voluntary enrollment.
COMPLETE ITEM 28 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER
In most cases, Medicare does not pay for health care you get whi le traveling outside the United States. Your local Social Security
office will be glad to explain more about Medicare.
Enrollment in Medicare Part B (Medical Insurance): Medicare Part B helps cover doctor’s services and outpatient care. It also covers
some other services that Medicare Part A doesn’t cover. Once you are enrolled in Medicare Part B, you will have to pay a monthly
premium. The date your Medicare Part B begins and the amount of the premium you must pay depends on the month you filed this
application with the Social Security Administration. Your premiums will be deducted from any monthly Social Security, Railroad
Retirement, or Office of Personnel Management benefit check you receive. If you do not receive such benefits, you will be notified
how to pay your premiums. You will get advance notice if there is any change in your premium amount.
If you do not enroll in Medicare Part B now, you can enroll later only during a specified enrollment period. If you enroll later, your
coverage may be delayed and you may have to pay a higher premium.
28. Do you want to e nrol l in Medicare Part B (Medical insurance)?
Yes
No
29. If you are within 2 months of age 65 or older, blind or disabled, do you want to file for
Yes
No
Supplemental Security Income?
30. Do you have any unsatisfied felony warrants for your arrest?
Yes
No
31. Do you have any unsatisfied Federal or State warrants for your arrest for violating
the conditions of your probation or parole?
Yes
No
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REMARKS
(You may use this space for any explanations. 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
orforms,anditistrueandcorrecttothebestofmyknowledge. Iunderstandthatanyonewhoknowinglygivesfalseor
misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may
be sent to prison, or face other penalties, or both.
Date (Month, day, year)
SIGNATURE OF APPLICANT
SIGNATURE
(First Name, Middle Initial, Last Name) (Writeinink.)
Telephone number(s) at which you may
be contacted during the day
SIGN
HERE
Direct Deposit Payment Address
(Financial Institution)
FOR
Routing Transit Number C/S Depositor Account Number
No Account
OFFICIAL
USE ONLY
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.)
ZIP Code
City and State
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 who know the applicant must
sign below, giving their full addresses. Also, print the applicant’s name in the 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)
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Form
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RECEIPT FOR YOUR CLAIM FOR SOCIALSECURITY RETIREMENT INSURANCE BENEFITS
DATE CLAIM RECEIVED
BEFORE
YOU RECEIVE A
SSA OFFICE
NOTICE OF AWARD
TELEPHONE NUMBER(S) TO
( ) -
CALL IF YOU HAVE A
QUESTION OR SOMETHING
AFTER
YOU RECEIVE A
TO REPORT
NOTICE OF AWARD
( ) -
Your application for Social Security benefits has been
there is some other change that may affect your
received and will be processed as quickly as possible.
claim, you—or someone for you—should report the
change. The changes to be reported are listed on
You should hear from us within days after you
page 8.
have given us all the information we requested. Some
claims may take longer if additional information is
Always give us your claim number when writing or
needed.
telephoning about your claim.
In the meantime, if you change your address, or if
If you have any questions about your claim, we will be
glad to help you.
CLAIMANT
SOCIAL SECURITY CLAIM NUMBER
Collection and Use of Information From Your Application—Privacy Act Notice/Paperwork
Reduction Act Notice
The Social Security Administration is authorized to collect the information requested on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You do
not have to give us the requested information. However, if you do not provide the information, we will be unable to
make an accurate and timely decision concerning your entitlement or a dependent’s entitlement to benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency for
determining eligibility for a government benefit or program, to a Congressional office requesting information on
your behalf, to an independent party for performance of research and statistical activities, or to the Department of
Justice for use in representing the Federal government.
We may also use this information when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find
or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you
do not agree to it.
Explanations about these and other reasons why information you provide may be used or given out are available in
Social Security offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement
- This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless
we display a valid Office of Management and Budget control number. We estimate that it will take about 10.5
minutes to read the instructions, gather the facts, and answer the questions.
SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213.
You
may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Send
only comments relating to our time estimate to this address, not the completed form.
Form
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CHANGES TO BE REPORTED AND HOW TO REPORT
Failure to report may result in overpayments that must be repaid, and in possible monetary penalties
You change your mailing address for checks or
Your stepchild is entitled to benefits on your record and
residence. (
To avoid delay in receipt of checks you
you and the stepchild’s parent divorce. Stepchild
should ALSO file a regular change of address notice
benefits are not payable beginning with the month after
with your post office
.)
the month the divorce becomes final.
Your citizenship or immigration status changes.
Custody Change – Report if a person for whom you
are filing or who is in your care dies, leaves your
care or custody, or changes address.
You go outside the U.S.A. for 30 consecutive days or
Change of Marital Status – Marriage, divorce,
longer.
annulment of marriage.
HOW TO REPORT
Any beneficiary dies or becomes unable to handle
You can make your reports by telephone, mail, or in
benefits.
person, whichever you prefer.
Work Changes — On your application you told us you
If you are awarded benefits, and one or more of the
expect total earnings for to be
above change(s) occur, you should report by:
(Year)
$ .
Calling us TOLL FREE at 1-800-772-1213.
You
earning wages of more
(are)
(are not)
If you are deaf or hearing impaired, calling us
than $ a month.
TOLL FREE at TTY 1-800-325-0778; or
Calling, visiting or writing your local Social
You
self-employed rendering
(are)
(are not)
Security office at the phone number and address
substantial services in your trade or business.
shown on your claim receipt.
(Report AT ONCE if this work pattern changes)
For general information about Social Security, visit
You are confined to jail, prison, penal institution or
our web site at www.socialsecurity.gov.
correctional facility for conviction of a crime or you are
confined to a public institution by court order in
For those under full retirement age, the law requires
connection with a crime.
that a report of earnings be filed with SSA within 3
months and 15 days after the end of any taxable
You have an unsatisfied warrant for your arrest for a
crime or attempted crime that is a felony (or, in
year in which you earn more than the annual
jurisdictions that do not define crimes as felonies, a
exempt amount. You may contact SSA to file a
crime that is punishable by death or imprisonment for
report. Otherwise, SSA will use the earnings
a term exceeding 1 year).
reported by your employer(s) and your
self-employment tax return (if applicable) as the
You have an unsatisfied warrant for a violation of
report of earnings required by law, to adjust benefits
probation or parole under Federal or State law.
under the earnings test. It is your responsibility to
ensure that the information you give concerning
You become entitled to a pension or annuity based on
your employment after 1956 not covered by Social
your earnings is correct. You must furnish
Security, or if such pension or annuity stops.
additional information as needed when your benefit
adjustment is not correct based on the earnings on
your record.
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
BEFORE YOU ANSWERQUESTION27.
If you are under full retirement age, retirement benefits cannot be payable to you for any month before the month in
which you file your claim.
If you are over full retirement age, retirement benefits may be payable to you for some months before the month in
which you file this c laim (but not before the month you attain full retirement age).
If your first month of entitlement is prior to full retirement age, your benefit rate will be reduced. However, if you do not
actually receive your full benefit amount for one or more months before full retirement age because benefits are
withheld due to your earnings, your benefit will be increased at full retirement age to give credit for this withholding.
Thus, your benefit amount at full retirement age will be reduced only if you receive one or more full benefit payments
prior to the month you attain full retirement age.
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