ࡱ> HJEFG'` !bjbj$$ 7 FF))))))))^^^^z)z]______$Xh)))))]]e)) 4\^ ()40!PPPP)  )))8b8)))b))))))))) SSA FORMS FormDescription1SSA-1695Identifying Information for Possible Direct Payment of Authorized Fees (SSA 1695 form) (9-06 version)2SSA 61Request for Review by a Federal Reviewing Official3SSA 3373-BKDisability Report Adult - SSA 3373 BK- 10 pages4SSA 3380-BKFUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK5SSA-3368-BKDISABILITY REPORTADULT Form SSA 3368 BK6SSA-3369-BKWork History Report - SSA 3369 BI7SSA-3820-BKDisability Report - Child - SSA 3820 BK8SSA 16-BKApplication for Disability Insurance Benefits9SSA 8000-BK (also known as SSA 8001-BK) (formerly 8001-FS)Application for Supplemental Security Income (10 pages; revised to 12/06 version and approved by SSA)10SSA 2506-BKPsychiatric Review Technique SSA 2506 BK11SSA 4734-BKPhysical Residual Functional Capacity Assessment SSA 4734 BK12SSA-4734-F4-SUPMENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT13SSA 1020Application for Help with Medicare Prescription Drug Plan Costs, SSA-102014SSA-3Marriage Certification - 2 pages15SSA-21Supplement to Claim of Person Outside the 16United States17SSA 131EMPLOYER REPORT OF SPECIAL WAGE PAYMENTS18SSA 150MODIFIED BENEFIT FORMULA QUESTIONNAIRE19SSA-308Modified Benefits Formula Questionnaire, Foreign Pension20SSA-521Request for Withdrawal of Application21SSA-545Plan for Achieving Self-Support22SSA-546Worker's Compensation/Public Disability Questionnaire23SSA 671Railroad Employment Questionnaire24SSA-723Statement Regarding the Inferred Death of an Individual25SSA-781Certificate of Responsibility for Welfare and Care of Child26SSA-782Form has been replaced by form SSA-3441-BK27SSA 783Statement Regarding Contributions28SSA 788STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY29SSA-789Request for Reconsideration - Disability Cessation30SSA 795STATEMENT OF CLAIMANT OR OTHER PERSON31SS-5Application for a Social Security Card32SS-5-FSApplication for a Social Security Card33SSA 820Work Activity Report (Self-Employed Person) 4 pages34SSA 831Work Activity Report (Employee) - 8 pages35SSA-827Authorization to Disclose Information to SSA36SSA 1199ADirect Deposit Sign-Up Form (SF-1199A) 371372-BKSTUDENT'S STATEMENT REGARDING SCHOOL ATTENDANCE (8 pages)38SSA 2512Pre-1957 Military Service - Federal Benefit Questionnaire (2 pages)39SSA 2519Child Relationship Statement40SSA-2000Application for Special Benefits for World War II Veterans41SSA-1696Appointment of Representative42HA-4631, 4632, & 4633Combines 4631, 4632, and 4633 into one convenient document!43HA-4633Claiman's Work Bankgroud - SSA 4633 & HA 463344HA-4632Claimant's Medications - SSA 4632 & HA 463245SSA 3369 BKWORK HISTORY REPORT-Form SSA-3369-BK (10 pages)46SSA 3441-BK (SSA3441)DISABILITY REPORT - APPEAL - Form SSA-3441-BK (10 pages)47HA-4631Claimant's Recent Medical Treatment - SSA 4631 & HA 463148SSA 538-F6Childhood Disability Evaluation Report (6 pages)49SSA 3820Disability Report - Child Form SSA-3820-BK (14 pages)50SSA 3881QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS (8 pages)51SSA 3885Government Pension Questionnaire52SSA 4162Child care Dropout Questionnaire (2 pages)53HA-4486Form has been replaced by form SSA-3441-BK54SSA 4184Self-Employment - Corporate Officer Questionnaire55SSATEACHER QUESTIONNAIRE (10 pages)56566557SSA 5666REQUEST FOR ADMINISTRATIVE INFORMATION (2 pages)58SSA 7008REQUEST FOR CORRECTION OF EARNINGS RECORD (2 pages)59SSA 7014Partnership Questionnaire60HA-4633Claimant's Work Background61SSA 7156Farm Self-Employment Questionnaire62SSA 7157Farm Arrangement Questionnaire63SSA 7163QUESTIONNAIRE ABOUT EMPLOYMENT OR SELF-EMPLOYMENT OUTSIDE THE UNITED STATES (2 pages)64SSA 7163ASUPPLEMENTAL STATEMENT REGARDING FARMING ACTIVITIES OF PERSON LIVING OUTSIDE THE U.S.A.65SSA 7050REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION (4 pages)66SSA-3288Consent for Release of Information67SSA-437Discrimination Complaint68SSA-131Employer Report of Special Wage Payments69HA-539Notice Regarding Substitution of Party Upon Death70SSA-1560Petition to Obtain Approval of a Fee for Representing a Claimant71SSA-3441-BKDisability Report - Appeal72HA-501Request for Hearing by Administrative Law Judge73SSA-561-U2Request for Reconsideration74HA-520Request for Review of Decision/Order of ALJ75SSA-632Request for Waiver of Overpayment Recovery76SSA-7004Request for Social Security Statement77SSA-7004-SPSolicitud de Declaracin de Ganancias78SS-5-SPSolicitud Para una Tarjeta de Seguro Social79HA-4608Waiver of Your Right to Personal Appearance Before an ALJ80HA-510Waiver of Written Notice of Hearing81SSA-783Statement Regarding Contributions82SSA-788Statement of Care and Responsibility for Beneficiary83SSA-795Statement of Claimant or Other Persons84SSA-820Work Activity Report (Self-Employed)85SSA-821Work Activity Report, Employee86SSA-1372Student's Statement Regarding School Attendance87SSA-1724Claim for Amounts Due in Case of a Deceased Beneficiary88SSA-2512Pre-1957 Military Service Federal Benefit Questionnaire89SSA-2519Child Relationship Statement90SSA-3820Disability Report, Child91SSA-3369Work History Report92SSA-3885Government Pension Questionnaire93SSA-4162Child Care Dropout Questionnaire94SSA-4184Self Employment Corporate Officer Questionnaire95SSA-4395Application for Access to SSA Headquarters Facilities96SSA-7008Request for Correction of Earnings Record97SSA-7050Request for Social Security Information98SSA-7104Partnership Questionnaire99SSA-7156Farm Self Employment Questionnaire100SSA-7157Farm Arrangement Questionnaire101SSA-7163Questionnaire About Employment or Self Employment Outside the 102US103SSA-7163AStatement Regarding Farming Activities of Persons Living Outside US104SSA-150Modified Benefits Formula Questionnaire105SSA-671Railroad Employment Questionnaire106SSA 6559Transmitter Report and Summary of Magnetic Media107SSA 6559-AContinuation Sheet for Form 6559108SF-1199ADirect Deposit Sign-Up Form109SSA-5665-BKTeacher Questionnaire110SSA-5666Request for Administrative Information111SSA-3881Questionnaire for Children Claiming SSI Benefits112SSA 8001 BK (also known as SSA 8001-BK; was SSA 8001BK-FS)Application for Suplemental Security Income (new form 12/06) 10 pages & approved by SSA     P Q , - V W   Q R d e   C D o p #$klPQ%&[\h{ mh{ mCJOJQJaJ&h{ mh{ m5CJOJQJ\^JaJ h{ mh{ mCJOJQJ^JaJhW{h{ mM  (yk$$Ifa$gd{ mykd$$IflwFp T3'     %   T36    44 lalpyt{ m $Ifgd{ m!xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m  P xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mP Q S _ xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m , xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m, - / j xmm $Ifgd{ m$$Ifa$gd{ mykdz$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykdk$$IflFp T3'    %  T36    44 lalpyt{ m  V xmm $Ifgd{ m$$Ifa$gd{ mykd\ $$IflwFp T3'    %  T36    44 lalpyt{ mV W Z j xmm $Ifgd{ m$$Ifa$gd{ mykdM $$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd> $$IflwFp T3'    %  T36    44 lalpyt{ m  xmm $Ifgd{ m$$Ifa$gd{ mykd/ $$IflwFp T3'    %  T36    44 lalpyt{ m   & Q xmm $Ifgd{ m$$Ifa$gd{ mykd $$IflwFp T3'    %  T36    44 lalpyt{ mQ R U V d vkk $Ifgd{ m$$Ifa$gd{ mzkd$$Ifl4wFp T3'`    % T36    44 lalpyt{ md e h p vkk $Ifgd{ m$$Ifa$gd{ mzkd $$Ifl4wFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd $$IflwFp T3'    %  T36    44 lalpyt{ m  xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m    C xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mC D G O o xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mo p s { xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m #xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m#$'/kxmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mklowxmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykds$$IflwFp T3'    %  T36    44 lalpyt{ mPxmm $Ifgd{ m$$Ifa$gd{ mykdd$$IflwFp T3'    %  T36    44 lalpyt{ mPQT\xmm $Ifgd{ m$$Ifa$gd{ mykdU$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdF$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd7$$IflwFp T3'    %  T36    44 lalpyt{ m%xmm $Ifgd{ m$$Ifa$gd{ mykd($$IflwFp T3'    %  T36    44 lalpyt{ m%&)1[xmm $Ifgd{ m$$Ifa$gd{ mykd$$IflwFp T3'    %  T36    44 lalpyt{ m[\_gxmm $Ifgd{ m$$Ifa$gd{ mykd $$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd $$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd!$$IflwFp T3'    %  T36    44 lalpyt{ mabTUYZ!"ijEFnoxyEFuvjk<=yz-.XY/0ghh{ mh{ mCJOJQJaJ h{ mh{ mCJOJQJ^JaJXaxmm $Ifgd{ m$$Ifa$gd{ mykd"$$IflwFp T3'    %  T36    44 lalpyt{ mabenxmm $Ifgd{ m$$Ifa$gd{ mykd#$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd$$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd%$$IflwFp T3'    %  T36    44 lalpyt{ mTxmm $Ifgd{ m$$Ifa$gd{ mykd&$$IflwFp T3'    %  T36    44 lalpyt{ mTUX`xmm $Ifgd{ m$$Ifa$gd{ mykd'$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd($$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdt)$$IflwFp T3'    %  T36    44 lalpyt{ m  Yxmm $Ifgd{ m$$Ifa$gd{ mykde*$$IflwFp T3'    %  T36    44 lalpyt{ mYZ]exmm $Ifgd{ m$$Ifa$gd{ mykdV+$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdG,$$IflwFp T3'    %  T36    44 lalpyt{ m!xmm $Ifgd{ m$$Ifa$gd{ mykd8-$$IflwFp T3'    %  T36    44 lalpyt{ m!"%.ixmm $Ifgd{ m$$Ifa$gd{ mykd).$$IflwFp T3'    %  T36    44 lalpyt{ mijmvxmm $Ifgd{ m$$Ifa$gd{ mykd/$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd 0$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd0$$IflwFp T3'    %  T36    44 lalpyt{ m Exmm $Ifgd{ m$$Ifa$gd{ mykd1$$IflwFp T3'    %  T36    44 lalpyt{ mEFIMnxmm $Ifgd{ m$$Ifa$gd{ mykd2$$IflwFp T3'    %  T36    44 lalpyt{ mnorwxvkk $Ifgd{ m$$Ifa$gd{ mzkd3$$Ifl4wFp T3'   `%   T36    44 lalpyt{ mxy|{pp $Ifgd{ m$$Ifa$gd{ mukd4$$Ifl4wFp T3'    %   T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd5$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd6$$IflwFp T3'    %  T36    44 lalpyt{ m"*Exmm $Ifgd{ m$$Ifa$gd{ mykd7$$IflwFp T3'    %  T36    44 lalpyt{ mEFIRuxmm $Ifgd{ m$$Ifa$gd{ mykd8$$IflwFp T3'    %  T36    44 lalpyt{ muvyxmm $Ifgd{ m$$Ifa$gd{ mykds9$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdd:$$IflwFp T3'    %  T36    44 lalpyt{ mjxmm $Ifgd{ m$$Ifa$gd{ mykdU;$$IflwFp T3'    %  T36    44 lalpyt{ mjknwxmm $Ifgd{ m$$Ifa$gd{ mykdF<$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd7=$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd(>$$IflwFp T3'    %  T36    44 lalpyt{ m <xmm $Ifgd{ m$$Ifa$gd{ mykd?$$IflwFp T3'    %  T36    44 lalpyt{ m<=@Gyxmm $Ifgd{ m$$Ifa$gd{ mykd @$$IflwFp T3'    %  T36    44 lalpyt{ myz}xmm $Ifgd{ m$$Ifa$gd{ mykd@$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdA$$IflwFp T3'    %  T36    44 lalpyt{ m-xmm $Ifgd{ m$$Ifa$gd{ mykdB$$IflwFp T3'    %  T36    44 lalpyt{ m-.1<Xxmm $Ifgd{ m$$Ifa$gd{ mykdC$$IflwFp T3'    %  T36    44 lalpyt{ mXY\cxmm $Ifgd{ m$$Ifa$gd{ mykdD$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdE$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdF$$IflwFp T3'    %  T36    44 lalpyt{ m /xmm $Ifgd{ m$$Ifa$gd{ mykdG$$IflwFp T3'    %  T36    44 lalpyt{ m/03;gxmm $Ifgd{ m$$Ifa$gd{ mykdH$$IflwFp T3'    %  T36    44 lalpyt{ mghksxmm $Ifgd{ m$$Ifa$gd{ mykdtI$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdeJ$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykdVK$$IflwFp T3'    %  T36    44 lalpyt{ m  KL~\]@Ano%&Z[+,45* + [ \ !!!!!!h{ mh{ mh{ mCJOJQJaJ h{ mh{ mCJOJQJ^JaJA  Kxmm $Ifgd{ m$$Ifa$gd{ mykdGL$$IflwFp T3'    %  T36    44 lalpyt{ mKLOW~xmm $Ifgd{ m$$Ifa$gd{ mykd8M$$IflwFp T3'    %  T36    44 lalpyt{ m~xmm $Ifgd{ m$$Ifa$gd{ mykd)N$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdO$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd P$$IflwFp T3'    %  T36    44 lalpyt{ m$\xmm $Ifgd{ m$$Ifa$gd{ mykdP$$IflwFp T3'    %  T36    44 lalpyt{ m\]`ixmm $Ifgd{ m$$Ifa$gd{ mykdQ$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdR$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdS$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdT$$IflwFp T3'    %  T36    44 lalpyt{ m@xmm $Ifgd{ m$$Ifa$gd{ mykdU$$IflwFp T3'    %  T36    44 lalpyt{ m@ADMnxmm $Ifgd{ m$$Ifa$gd{ mykdV$$IflwFp T3'    %  T36    44 lalpyt{ mnor{xmm $Ifgd{ m$$Ifa$gd{ mykdW$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdX$$IflwFp T3'    %  T36    44 lalpyt{ m%xmm $Ifgd{ m$$Ifa$gd{ mykduY$$IflwFp T3'    %  T36    44 lalpyt{ m%&)2Zxmm $Ifgd{ m$$Ifa$gd{ mykdfZ$$IflwFp T3'    %  T36    44 lalpyt{ mZ[^gxmm $Ifgd{ m$$Ifa$gd{ mykdW[$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdH\$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykd9]$$IflwFp T3'    %  T36    44 lalpyt{ m+xmm $Ifgd{ m$$Ifa$gd{ mykd*^$$IflwFp T3'    %  T36    44 lalpyt{ m+,014vkk $Ifgd{ m$$Ifa$gd{ mzkd_$$Ifl4wFp T3'`    % T36    44 lalpyt{ m459Cvkk $Ifgd{ m$$Ifa$gd{ mzkd`$$Ifl4wFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykda$$IflwFp T3'    %  T36    44 lalpyt{ mxmm $Ifgd{ m$$Ifa$gd{ mykdb$$IflwFp T3'    %  T36    44 lalpyt{ m* xmm $Ifgd{ m$$Ifa$gd{ mykdb$$IflwFp T3'    %  T36    44 lalpyt{ m* + / : [ xmm $Ifgd{ m$$Ifa$gd{ mykdc$$IflwFp T3'    %  T36    44 lalpyt{ m[ \ ` i xmm $Ifgd{ m$$Ifa$gd{ mykdd$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykde$$IflwFp T3'    %  T36    44 lalpyt{ m xmm $Ifgd{ m$$Ifa$gd{ mykdf$$IflwFp T3'    %  T36    44 lalpyt{ m !xmm $Ifgd{ m$$Ifa$gd{ mykdg$$IflwFp T3'    %  T36 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