Form ssa 3368 bk 012010 ef 042010 destroy prior editions page 1. Disability report adult social security administration. The ssa has other forms which they will ask your doctor to fill out on your behalf. If you have any questions, you may call us tollfree at 180077212 monday through friday from 7 a. Preapplication workers compensationpublic disability questionnaire view and download form. You can file form ssa 3368 online with the social security administration ssa. Work history report form ssa3369 bk read all of this information before you begin completing this form if you need help if you need help with this form, complete as much of it as you can.
Completing this report accurately and completely will help us. Form ssa 3368 is the basic form used for adults who are claiming disability benefits. If you have all the information, it should only take about 20 minutes to complete. Disability report adult form ssa3368bk please read all of this information before you begin completing this form this is. How to fill out form ssa3368bk in san jose angelina valle. Social security administration form approved omb no. The ssa will consider you a disabled person if you are unable to do any job you are fit for and if. You file it when you first apply for social security disability or supplemental security income ssi benefits.
Edit, fill, sign, download form ssa 3368 online on. Create form ssa 3368 bk in minutes using a fillable pdf editor. Ssa 3368 fillable form pdf form ssa 3368 bk 112014 ef 112014. The social security disability process is often confusing, and finding answers difficult.
Form ssa3373 bk is used to report an adult individuals ability to function. Fill disability report adult form ssa 3368 bk social security ssa instantly, download blank or editable online. If the fo is completing the ssa3369 along with the ssa 3368 and sending it to the dds, cross out section 6 of the ssa 3368, annotate see ssa3369, and go to section 7. The ssa understands the word disability as the inability to work. Personal training invoice template free download send in full template. You can fill the form out yourself or have a representative such as a social security disability lawyer help you with it, but you should not have your doctor fill out any of it. Many forms must be completed only by a social security representative. The form you are looking for is not available online. These forms are specific to child ssi applications. For the latest information about developments related to form.
Applying for social security disability insurance form ssa3368bk done. Work history report form ssa3369 bk form ssa3369 bk 042011 ef 042011 destroy prior editions social security administration work history report form approved omb no. Typically, the process of applying for disability begins with you filing an initial claim for benefits and submitting a form. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form for help to finish it. Form ssa3369 bk is a work history report for adults who are seeking to receive disability benefits from the social security administration. Social security administration ssa forms and resources. Form ssa3368bk download fillable pdf or fill online disability. Form ssa 3368 bk 102015 uf 102015 what we mean by disability disability under social security is based on your inability to work. Soar recommends that case managers use the paper form as a worksheet and transfer the information to the online application. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form. How to fill out form ssa3369bk in san jose angelina.
I apply for a period of disability andor all insurance benefits for which i am eligible under title ii and part a of title xviii of the social security act. It also goes by the adult disability report or the adult function report. Fill out, securely sign, print or email your ssa 3368 20152018 form instantly with signnow. Form approved social security administration tel toe 120145 omb no. We have also converted many of the social security online handbooks into pdf format so you can. Homepage forms social security disability application form ssa 3368 social security disability application form ssa 3368 by admin posted on february 23, 2019. The ssa3369 bk includes space for identifying information. Sample application for disability benefits ssa 16 bk and ssa 3368 bk. A form ssa 3368bk is known as an adult disability report.
Download ssa1696u4, appointment of representative, for free, powered by. Social security disability application form ssa 3368. Social security form ssa3373 bk is a lengthy form that you fill out as a part of the process of applying for social security disability benefits. Hearing preparation disability report appeal view and download form ssa3441 bk. You can use this as a guide to prepare for completing the ssa bear in mind that filling out form ssa is only the first step in claiming disability benefits. This disability report form is the launching point from which your entire medical eligibility decision will evolve. Disability report adult form ssa 3368 bk please read all of this information before you begin completing this form this is not an application. Page 1 disabilit y report a dultform ss a 3368 bk form ssa 3368 bk.
The instructions, gather the facts, and answer the questions. For purposes of this claim, we want you to understand that disability means you are unable to work as defined by the social security act. Ssa 3368 bk please read this information before completing this report the information you give us on this report will be used by the office that makes the disability decision on your disability claim. You may fill it out yourself or, if it makes you feel more comfortable, you may have a social security disability attorney or advocate help you fill it out. Hearing request claimants statement when request for hearing is filed and issue is disability view and download form ha4486. How to fill out form ssa3368bk in san jose angelina. Adult disability report social security disability. If the claimant had only one job in the last 15 years, then you may find. Form ssa16 062018 uf discontinue prior editions social security administration. The information provided will be used in making a decision of this claim. I apply for a period of disability andor 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. Free training plan templates for business use smartsheet.
Sample application for disability benefits ssa 16 bk and. The information within the report is used to determine whether the applicant meets the ssas qualifications to be considered disabled. How to fill out an application for disability benefits ssa 16 bk and ssa 3368 bk if you applied in person, you have already done this. The adult function report is used by the social security administration as part of the criteria used to determine whether an individual qualifies to receive disability payments. The information you give us on this report will be used by the office that makes the disability. Ssa 3368 is the basic form all social security disability claimants must fill out to apply for social security disability benefits. The disability determination services dds or the field office fo will complete the identifying information in every case in which completion of the ssa3369 bk.
Form ssa 3380 bk 12 2009 fill out and sign printable pdf. Please call us at 180077212 tty 18003250778 monday through friday between 8 a. You will usually receive a copy of the actual application form not this ssa3368 or other forms. Get this information from the ssa 3368 bk or other form in file. Use your own words if you do not know the medical name. You will find job history information on form ssa 3368 bk, section 6 you will find a list of jobs with basic information in section 6. Sample application for disability benefits ssa 16 bk and ssa.
In this article, well discuss the ssa 3368 paper form. How to fill out form ssa3368 disability benefits center. Ssa 3368 bk is the basic form which must be completed by every adult who applies for any social security disability insurance benefits, including ssdi, ssi, disabled spouse, exspouse or. The information requested on this form is authorized by section 223 and section 1633 of the social security act. However it gives you sample completed copies of every form, plus stepbystep instructions for each form.
Form ssa 3368 bk is a disability report for adults that is used by the social security administration. Form ssa8001 bk 072015 page 1 destroy prior editions b spouses other names including name at birth social security number c parent 1 s other names including name at birth social security. Sign, fax and printable from pc, ipad, tablet or mobile. Form ssa4734 bk 122004 ef 122004 formerly ssa4734u8 use prior editions page 1 insured. Work history report social security administration.
Initiated by applicants beneficiaries appealing disability determination. Ssa form 3368, the adult disability report, is the most comprehensive and, some argue, the most important of the forms that you will fill out when applying for disability benefits from the social security administration. The information that you give us on this report tells us where to request your medical and other records. Disability report adult form ssa 3368 bk please read all of this information before you begin completing this form tills is not an application if you need help if you need help with this form. This form is a major part of any application for social security disability or ssi benefits. The most secure digital platform to get legally binding, electronically signed. Send the completed form to your local social security office. If you need help with this form, do as much of it as you can, and your interviewer will help you finish it. Form ssa 3368 bk 112014 ef 112014 what we mean by disability disability under social security is based on your inability to work. The purpose of the form is to help the ssa determine whether the individual completing is qualifies for disability income. Fillable form ssa454bk free printable pdf sample formswift. However, if you have access to the internet, you may access the disability. Social security forms social security administration.
Work history report view and download form ssa3369 bk. Do not write in this space application for disability. Ssa 3368 form online printable fill out and sign printable pdf. If you need help with form ssa3368, contact us now. Form ssa 3368 bk 012010 ef 042010 what we mean by disability disability under social security is based on your inability to work. You should include copies of all of your pertinent medical records when you turn this form in. This form will be used by the united states social security administration. Mark reinke the value of having a plan a personal full template.
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