Form SSA-16 PDF Download : How To Fill Form SSA-16 PDF 2024

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Form SSA-16 PDF Download:-Form SSA-16 is an application for Disability Insurance Benefits. It is a seven-page form that asks for detailed information about your medical condition, work history, and other factors that may affect your eligibility for benefits. You can download a PDF of Form SSA-16 from the Social Security Administration (SSA) website: https://www.ssa.gov/forms/ssa-16.pdf You can also apply for Disability Insurance Benefits online or by calling the SSA at 1-800-772-1213.

Form SSA-16 is an application for Disability Insurance Benefits. You can download a PDF of the form from the SSA website or apply online or by calling the SSA.

Form SSA-16 | Information You Need to Apply for Disability Benefits

You can apply:

• Online
• By calling our national toll-free service at 1-800-772-1213 (TTY 1-800-325-0778) or visiting your local Social Security office. An appointment is not required, but if you call ahead and schedule one, it may reduce the time you spend waiting to apply.

You can help by being ready to:

• Provide any needed documents; and
• Answer the questions listed below.

Documents you may need to provide

We may ask you to provide documents to show that you are eligible, such as:

• Birth certificate or other proof of birth;
• Proof of U.S. citizenship or lawful alien status if you were not born in the United States;
• U.S. military discharge paper(s) if you had military service before 1968;
• W-2 forms(s) and/or self-employment tax returns for last year;
• An Adult Disability Report that collects more details about your illnesses, injuries or conditions, and your work history;
• Medical evidence already in your possession. This includes medical records, doctors’ reports, and recent test results; and
• Award letters, pay stubs, settlement agreements or other proof of any temporary or permanent workers’ compensation-type benefits you received

Proof of Workers’ Compensation And /Or Similar Benefits

If you receive or received any temporary or permanent workers’ compensation-type benefits, we need to see award letters, pay stubs, settlement agreements or other proof you might have.

We will need documents that show:

• The date of your injury or illness;
• The amount and effective date of your current payment and all increases or decreases within the last 17 months or, if later, since payments began;
• if receiving workers’ compensation, the type of payment (i.e., temporary partial, temporary total, permanent partial, permanent total, a lump sum or an annuity;
• The frequency of your payments (e.g. weekly, bi-weekly, monthly, bi-monthly, etc.) or the period covered by a lump sum;
• If benefits have already ended, the last day you were entitled to a payment and your last payment amount (if different than your regular payment amount);
• Your employer’s name and address; and
• If other than your employer, the name and address of the insurance carrier making the payments.

For your convenience, we can accept uncertified photocopies of your workers’ compensation and/or similar benefit information. We will return all documents and photocopies unless you specifically tell us otherwise. If you have the documents we need, you should submit them as soon as possible. If you don’t have all the documents, you should submit any documents you do have. We will help you get the other documents. Do not delay sending your application while gathering evidence. If you do, you may lose benefits.

Note: If you mail any documents to us, we must have your Social Security Number so we can match them with your claim. Please write your Social Security Number on a separate sheet of paper and include it in the mailing envelope along with your documents. Do not write anything on your original documents.

If you do not want to mail your documents or photocopies, you may bring them to the Social Security office where they will be examined and returned to you. Or, if a later office visit becomes necessary, you may bring them with you at that time.

Important:-We accept photocopies of W-2 forms, self-employment tax returns or medical documents, but we must see the original of most other documents, such as your birth certificate. (We will return them to you.) Do not delay applying for benefits because you do not have all the documents. We will help you get them.

What we will ask you 2023-24

• Your name, gender and Social Security number;
• Your name at birth (if different);
• Your date of birth and place of birth (State or foreign country);
• Whether a public or religious record was made of your birth before age 5;
• Your citizenship status;
• Whether you or anyone else has ever filed for Social Security benefits, Medicare or Supplemental Security Income on your behalf (if so, we will also ask for information on whose Social Security record you applied);
• Whether you have used any other Social Security number; 
• Whether you were ever in the active military service before 1968 and, if so, the dates of service and whether you have ever been eligible to receive a monthly benefit from a military or Federal civilian agency;
• Whether you or your spouse have ever worked for the railroad industry;
• Whether you have earned Social Security credits under another country’s Social Security system;
• Whether you qualified for or expect to receive a pension or annuity based on your own employment with the Federal government of the United States or one of its States or local subdivisions;
• Whether you are currently married and, if so, your spouse’s name, date of birth (or age) and Social Security number (if known);
• The names, dates of birth (or age) and Social Security numbers (if known) of any former spouses;
• The dates and places of each of your marriages and, for marriages that have ended, how and when they ended;
• The names of any unmarried children under age 18, age 18-19 and in elementary or secondary school, or disabled before age 22;
• Whether you have or had a child under age 3 living with you during a calendar year when you had no earnings;
• Whether you have a parent who was dependent on you for 1/2 of his or her support at the time you became disabled;
• Whether you had earnings in all years since 1978;
• The name(s) of your employer(s) or information about your self-employment and the amount of your earnings for this year and last year;
• Whether you received or expect to receive any money from an employer since the date you became unable to work;
• Whether you have any unsatisfied felony or arrest warrants for escape from custody, flight to avoid prosecution or confinement, or flight-escape;
• The date you became unable to work because of illnesses, injuries or conditions and if you are still unable to work; and
• Information about any workers’ compensation, black lung, and/or similar benefits you filed, or intend to file for. These benefits can:
  • Be temporary or permanent in nature;
  • Include annuities and lump sum payments that you received in the past; and
  • Be paid by your employer or your employer’s insurance carrier, private agencies, or Federal, State or other government or public agencies.

Some examples include:

• Workers’ Compensation
• Black Lung Benefits
• Longshore and Harbor Workers’ Compensation
• Civil Service Retirement
• Federal Employees’ Retirement
• Federal Employees’ Compensation
• State Disability Insurance benefits
• Military retirement pensions based on disability

Note:-You also should bring along your checkbook or other papers that show your account number at a bank, credit union or other financial institution so you can sign up for Direct Deposit, and avoid worries about lost or stolen checks and mail delays.

Online Disability Benefit Application 

This article walks the case manager through Step 1 of the Online Disability Benefit Application, “Provide Background Information,” which includes information collected on the paper form SSA-16: Application for SSDI.

1. Go to SSA’s Website

• Go to https://www.ssa.gov/benefits/disability/
  • Alternatively, go to https://www.ssa.gov/ and click on Benefits, then Disability

2. Select Apply for Disability

• This will bring you to https://secure.ssa.gov/iClaim/dib

Agree to the Benefits Application Terms of Service

Check the “I Understand and agree” box, and click Next

Start a New or Return to a Saved Application

• Choose Start a New Application
  • Select Return to a Saved Application only if you have previously set the protective filing date, have a re-entry number, and are ready to complete/submit the application.

5. Who is Completing this Application?
   • If the Applicant is with you, choose “I am applying for myself.” The applicant will need to create a my Social Security account.
   • If the Applicant is not with you, choose “I am helping someone who is not with me, and therefore cannot sign the application at this time.” You will still be able to enter enough information to set the Protective Filing Date and get a re-entry number.
   • Applicants often have difficulty creating a my Social Security Account. Please see the Creating a my Social Security Account Flowchart for guidance.

Completing the Application 2023-24

Navigation Tips

• Use the “Previous” and “Next” buttons to move forward or back. Do not use computer backspace key or arrow keys.
• This application does not allow you to move forward until all of the appropriate information has been completed.
• Tabs at the top will identify the various segments of the application and show where you are. When a section is completed, a green check mark will appear on the tab.
• The application uses dynamic pathing – that is, depending upon Yes/No response, the appropriate questions will appear. For this reason, no two applications will look alike.

Tabs 1-3

The first three tabs require detailed information to be provided.

• If the name, date of birth, and Social Security number do not match, the application cannot be completed; contact the local SSA office for assistance.
• If all the information is available, the form takes 10 to 15 minutes to fill out.

Tab 1: Identification

• Demographic information
• Basic disability questions
• Birth and citizenship information
• Contact information
• Preparer’s contact information (the SOAR representative)
  • There is a drop-down box for the representative to list their relationship to the applicant (i.e., non-attorney representative, legal aid group, health service agency, etc.)

You have now set the Protective Filing Date (PFD). A re-entry number is assigned at this point. DO NOT proceed past this screen until you are prepared to submit the complete application packet, as this will trigger SSA to set up an interview to complete the application.

Tab 2: General

• Other Social Security numbers or names (e.g., a different birth name or previous married name)
• Marriage and dependent information
• Employment information
• Eligibility for other benefits
• Direct deposit information – bank account information

Tab 3: Other Benefits

• Inquiry about other benefits
• Ability to work
• Other benefit payments
• Disability payments
• Employment wage information
• Authorization for disclosure of medical information

iSSI: Online SSI Application

When the applicant indicates their intent to file for Supplemental Security Income (SSI), they may be eligible to complete the iSSI (a limited, deferred SSI Application). They must meet certain criteria – you will learn more about this in the next course article.

• If eligible for iSSI, the application presents an additional question about the household. The answer to this question determines what information is shown about applying for SNAP:

• If the claimant is not eligible for iSSI (for example, currently or previously married is currently an exclusion for iSSI), then the question about the household will not appear and the applicant will be asked about prior applications:

Tab 4: Remarks

This screen allows the individual to describe their situation. 

• To the extent possible, use the person’s own words.
• Add that this is a SOAR application! It is also helpful to document if the applicant is experiencing homelessness.
• This section also allows an individual to cancel any previously scheduled appointments with the local SSA field office:

Tab 5: Accept and Continue to Step 2

This page summarizes all the information provided.

• Review carefully – this is the place to make any necessary corrections.
• The applicant should check the box indicating, “I agree with the Electronic Signature Agreement.”
• The applicant should then click “Accept and Continue to Step 2.”
• Note: The applicant should not click the button until the case manager is ready to submit the complete SOAR application packet. Information in this section cannot be changed once the application proceeds to Step 2, “Provide Disability Information.”

Tab 6: Next Steps

• This tab provides a “receipt” and a date the application was received.
• It describes to the applicant additional steps that will be necessary, including providing documentation:
  • Original birth certificate or certified copy as proof of birth
  • Citizenship/naturalization papers
  • U.S. Military Certificate of Release or Discharge from Active Duty
  • Documentation of wages for previous year (e.g. IRS Form W-2)
• Directions to complete the Disability Application Process
  • Steps 2-4 make up Online Adult Disability Report (online version of the SSA-3368: Adult Disability Report)
  • You will learn more about this in Class 4.