SSA FORMS
SSA FORMS
| |Form |Description |
|1 |SSA-1695 |Identifying Information for Possible Direct Payment of Authorized Fees (SSA 1695 form) (9-06 version) |
|2 |SSA 61 |Request for Review by a Federal Reviewing Official |
|3 |SSA 3373-BK |Disability Report Adult - SSA 3373 BK- 10 pages |
|4 |SSA 3380-BK |FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK |
|5 |SSA-3368-BK |DISABILITY REPORT—ADULT— Form SSA 3368 BK |
|6 |SSA-3369-BK |Work History Report - SSA 3369 BI |
|7 |SSA-3820-BK |Disability Report - Child - SSA 3820 BK |
|8 |SSA 16-BK |Application for Disability Insurance Benefits |
|9 |SSA 8000-BK (also known as SSA 8001-BK) |Application for Supplemental Security Income (10 pages; revised to 12/06 version and approved by SSA) |
| |(formerly 8001-FS) | |
|10 |SSA 2506-BK |Psychiatric Review Technique SSA 2506 BK |
|11 |SSA 4734-BK |Physical Residual Functional Capacity Assessment SSA 4734 BK |
|12 |SSA-4734-F4-SUP |MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT |
|13 |SSA 1020 |Application for Help with Medicare Prescription Drug Plan Costs, SSA-1020 |
|14 |SSA-3 |Marriage Certification - 2 pages |
|15 |SSA-21 |Supplement to Claim of Person Outside the |
|16 | |United States |
|17 |SSA 131 |EMPLOYER REPORT OF SPECIAL WAGE PAYMENTS |
|18 |SSA 150 |MODIFIED BENEFIT FORMULA QUESTIONNAIRE |
|19 |SSA-308 |Modified Benefits Formula Questionnaire, Foreign Pension |
|20 |SSA-521 |Request for Withdrawal of Application |
|21 |SSA-545 |Plan for Achieving Self-Support |
|22 |SSA-546 |Worker's Compensation/Public Disability Questionnaire |
|23 |SSA 671 |Railroad Employment Questionnaire |
|24 |SSA-723 |Statement Regarding the Inferred Death of an Individual |
|25 |SSA-781 |Certificate of Responsibility for Welfare and Care of Child |
|26 |SSA-782 |Form has been replaced by form SSA-3441-BK |
|27 |SSA 783 |Statement Regarding Contributions |
|28 |SSA 788 |STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY |
|29 |SSA-789 |Request for Reconsideration - Disability Cessation |
|30 |SSA 795 |STATEMENT OF CLAIMANT OR OTHER PERSON |
|31 |SS-5 |Application for a Social Security Card |
|32 |SS-5-FS |Application for a Social Security Card |
|33 |SSA 820 |Work Activity Report (Self-Employed Person) 4 pages |
|34 |SSA 831 |Work Activity Report (Employee) - 8 pages |
|35 |SSA-827 |Authorization to Disclose Information to SSA |
|36 |SSA 1199A |Direct Deposit Sign-Up Form (SF-1199A) |
|37 |1372-BK |STUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE (8 pages) |
|38 |SSA 2512 |Pre-1957 Military Service - Federal Benefit Questionnaire (2 pages) |
|39 |SSA 2519 |Child Relationship Statement |
|40 |SSA-2000 |Application for Special Benefits for World War II Veterans |
|41 |SSA-1696 |Appointment of Representative |
|42 |HA-4631, 4632, & 4633 |Combines 4631, 4632, and 4633 into one convenient document! |
|43 |HA-4633 |Claiman's Work Bankgroud - SSA 4633 & HA 4633 |
|44 |HA-4632 |Claimant's Medications - SSA 4632 & HA 4632 |
|45 |SSA 3369 BK |WORK HISTORY REPORT-Form SSA-3369-BK (10 pages) |
|46 |SSA 3441-BK (SSA3441) |DISABILITY REPORT - APPEAL - Form SSA-3441-BK (10 pages) |
|47 |HA-4631 |Claimant's Recent Medical Treatment - SSA 4631 & HA 4631 |
|48 |SSA 538-F6 |Childhood Disability Evaluation Report (6 pages) |
|49 |SSA 3820 |Disability Report - Child Form SSA-3820-BK (14 pages) |
|50 |SSA 3881 |QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS (8 pages) |
|51 |SSA 3885 |Government Pension Questionnaire |
|52 |SSA 4162 |Child care Dropout Questionnaire (2 pages) |
|53 |HA-4486 |Form has been replaced by form SSA-3441-BK |
|54 |SSA 4184 |Self-Employment - Corporate Officer Questionnaire |
|55 |SSA |TEACHER QUESTIONNAIRE (10 pages) |
|56 |5665 | |
|57 |SSA 5666 |REQUEST FOR ADMINISTRATIVE INFORMATION (2 pages) |
|58 |SSA 7008 |REQUEST FOR CORRECTION OF EARNINGS RECORD (2 pages) |
|59 |SSA 7014 |Partnership Questionnaire |
|60 |HA-4633 |Claimant's Work Background |
|61 |SSA 7156 |Farm Self-Employment Questionnaire |
|62 |SSA 7157 |Farm Arrangement Questionnaire |
|63 |SSA 7163 |QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES (2 pages) |
|64 |SSA 7163A |SUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES OF PERSON LIVING OUTSIDE THE U.S.A. |
|65 |SSA 7050 |REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION (4 pages) |
|66 |SSA-3288 |Consent for Release of Information |
|67 |SSA-437 |Discrimination Complaint |
|68 |SSA-131 |Employer Report of Special Wage Payments |
|69 |HA-539 |Notice Regarding Substitution of Party Upon Death |
|70 |SSA-1560 |Petition to Obtain Approval of a Fee for Representing a Claimant |
|71 |SSA-3441-BK |Disability Report - Appeal |
|72 |HA-501 |Request for Hearing by Administrative Law Judge |
|73 |SSA-561-U2 |Request for Reconsideration |
|74 |HA-520 |Request for Review of Decision/Order of ALJ |
|75 |SSA-632 |Request for Waiver of Overpayment Recovery |
|76 |SSA-7004 |Request for Social Security Statement |
|77 |SSA-7004-SP |Solicitud de Declaración de Ganancias |
|78 |SS-5-SP |Solicitud Para una Tarjeta de Seguro Social |
|79 |HA-4608 |Waiver of Your Right to Personal Appearance Before an ALJ |
|80 |HA-510 |Waiver of Written Notice of Hearing |
|81 |SSA-783 |Statement Regarding Contributions |
|82 |SSA-788 |Statement of Care and Responsibility for Beneficiary |
|83 |SSA-795 |Statement of Claimant or Other Persons |
|84 |SSA-820 |Work Activity Report (Self-Employed) |
|85 |SSA-821 |Work Activity Report, Employee |
|86 |SSA-1372 |Student's Statement Regarding School Attendance |
|87 |SSA-1724 |Claim for Amounts Due in Case of a Deceased Beneficiary |
|88 |SSA-2512 |Pre-1957 Military Service Federal Benefit Questionnaire |
|89 |SSA-2519 |Child Relationship Statement |
|90 |SSA-3820 |Disability Report, Child |
|91 |SSA-3369 |Work History Report |
|92 |SSA-3885 |Government Pension Questionnaire |
|93 |SSA-4162 |Child Care Dropout Questionnaire |
|94 |SSA-4184 |Self Employment Corporate Officer Questionnaire |
|95 |SSA-4395 |Application for Access to SSA Headquarters Facilities |
|96 |SSA-7008 |Request for Correction of Earnings Record |
|97 |SSA-7050 |Request for Social Security Information |
|98 |SSA-7104 |Partnership Questionnaire |
|99 |SSA-7156 |Farm Self Employment Questionnaire |
|100 |SSA-7157 |Farm Arrangement Questionnaire |
|101 |SSA-7163 |Questionnaire About Employment or Self Employment Outside the |
|102 | |US |
|103 |SSA-7163A |Statement Regarding Farming Activities of Persons Living Outside US |
|104 |SSA-150 |Modified Benefits Formula Questionnaire |
|105 |SSA-671 |Railroad Employment Questionnaire |
|106 |SSA 6559 |Transmitter Report and Summary of Magnetic Media |
|107 |SSA 6559-A |Continuation Sheet for Form 6559 |
|108 |SF-1199A |Direct Deposit Sign-Up Form |
|109 |SSA-5665-BK |Teacher Questionnaire |
|110 |SSA-5666 |Request for Administrative Information |
|111 |SSA-3881 |Questionnaire for Children Claiming SSI Benefits |
|112 |SSA 8001 BK (also known as SSA 8001-BK; |Application for Suplemental Security Income (new form 12/06) 10 pages & approved by SSA |
| |was SSA 8001BK-FS) | |
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