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<a class="cc" href="https://www.ssa.gov/benefits/retirement/social-security-fairness-act.html"><u>Information about the Social Security Fairness Act (WEP/GPO)</u></a>
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<p>All forms are <strong>FREE</strong>. Not all forms are listed. If you can't find the form you need, or you need help completing a form, please call us at <strong>1-800-772-1213 (TTY 1-800-325-0778)</strong> or contact your <a href="https://secure.ssa.gov/ICON/main.jsp">local Social Security office</a> and we will help you. If you download, print and complete a paper form, please mail or take it to your <a href="https://secure.ssa.gov/ICON/main.jsp">local Social Security office</a> or the office that requested it from you.</p>
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<p><strong>Important Note:</strong> PDFs you open from this page may default to opening within a browser, depending on your browser settings. Most modern browsers (Microsoft Edge, Google Chrome, etc.) do not allow PDFs to open/display properly within the browser. These PDFs may not function consistently/as intended while both filling it out and using a screen reader. For the best experience, open PDFs in Adobe Reader (<a href="https://get.adobe.com/reader/" title="Adobe Reader Link" target="new">free download</a>). Thank you!</p>
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<section aria-atomic="true" aria-live="assertive" aria-relevant="all" class="alert-red dn mt3" id="js-search-message" role="alert" tabindex="-1">The form you are looking for is not available online.  Many forms must be completed only by a Social Security Representative.  Please call us at <strong>1-800-772-1213</strong> (TTY <strong>1-800-325-0778</strong>) Monday through Friday between 8 a.m. and 5:30 p.m. or <a href="/agency/contact/">contact your local Social Security office</a>.</section>
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<td class="va-t">SS-5</td>
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<td><a class="bgi-none db" href="ss-5.pdf" rel="noopener noreferrer" target="_blank">Application for a Social Security Card</a>
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<div><strong><small>In some areas, you may <a href="/ssnumber/">request a replacement Social Security card online</a>.</small></strong></div>
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</td>
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<tr>
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<td class="va-t">SSA-827</td>
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<td><a class="bgi-none db" href="ssa-827.pdf" rel="noopener noreferrer" target="_blank">Authorization to Disclose Information to the Social Security Administration</a></td>
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<tr>
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<td class="va-t">SSA-3820-BK</td>
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<td><a class="bgi-none db" href="ssa-3820.pdf" rel="noopener noreferrer" target="_blank">Disability Report - Child</a></td>
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<td class="va-t">IRS W-4V</td>
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<td><a class="bgi-none db" href="https://www.irs.gov/forms-pubs/about-form-w-4-v" rel="noopener noreferrer" target="_blank">Voluntary Withholding Request</a></td>
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<tr>
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<td class="va-t">CMS-40B</td>
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<td><a class="bgi-none db" href="https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS017339.html" rel="noopener noreferrer" target="_blank">Application for Enrollment in Medicare - Part B (Medical Insurance)</a></td>
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</tr>
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<tr>
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<td class="va-t">CMS-L564</td>
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<td><a class="bgi-none db" href="https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS009718.html" rel="noopener noreferrer" target="_blank">Request for Employment Information</a></td>
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<td class="va-t">CMS-L564S</td>
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<td><a class="bgi-none db" href="https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564S.pdf" rel="noopener noreferrer" target="_blank">Solicitud De Información Sobre El Empleo</a></td>
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</tr>
|
|
<tr>
|
|
<td class="va-t">HA-85</td>
|
|
<td><a class="bgi-none db" href="ha-85.html" rel="noopener noreferrer" target="_blank">Request to Withdraw a Hearing Request</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-86</td>
|
|
<td><a class="bgi-none db" href="ha-86.pdf" rel="noopener noreferrer" target="_blank">Discontinue Prior Editions</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-86-SP</td>
|
|
<td><a class="bgi-none db" href="ha-86-sp.pdf" rel="noopener noreferrer" target="_blank">SOLICITUD PARA RETIRAR UNA PETICIÓN PARA REVISIÓN CON EL CONSEJO DE APELACIONES </a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-501-U5</td>
|
|
<td><a class="bgi-none db" href="ha-501.html" rel="noopener noreferrer" target="_blank">Request for Hearing by Administrative Law Judge</a></td>
|
|
</tr>
|
|
<tr> <td class="va-t">HA-510</td>
|
|
<td><a class="bgi-none db" href="ha-510.pdf" rel="noopener noreferrer" target="_blank">Waiver of Timely Written Notice of Hearing</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-510-SP</td>
|
|
<td><a class="bgi-none db" href="ha-510sp.pdf" rel="noopener noreferrer" target="_blank">Renuncia a la notificación escrita oportuna de la audiencia</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-520</td>
|
|
<td><a class="bgi-none db" href="ha-520.html" rel="noopener noreferrer" target="_blank">Request for Review of Hearing Decision/Order</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-539</td>
|
|
<td><a class="bgi-none db" href="ha-539.html" rel="noopener noreferrer" target="_blank">Notice Regarding Substitution of Party Upon Death of Claimant</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-539-SP</td>
|
|
<td><a class="bgi-none db" href="ha-539-sp.pdf" rel="noopener noreferrer" target="_blank">Aviso Sobre La Substitución De La Parte Interesada Tras El Fallecimiento Del Reclamante</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-4608</td>
|
|
<td><a class="bgi-none db" href="ha-4608.html" rel="noopener noreferrer" target="_blank">Waiver of Your Right to Personal Appearance Before an Administrative Law Judge</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-4631</td>
|
|
<td><a class="bgi-none db" href="ha-4631.html" rel="noopener noreferrer" target="_blank">Claimant's Recent Medical Treatment</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-4632</td>
|
|
<td><a class="bgi-none db" href="ha-4632.html" rel="noopener noreferrer" target="_blank">Claimant's Medications</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">HA-4633</td>
|
|
<td><a class="bgi-none db" href="ha-4633.html" rel="noopener noreferrer" target="_blank">Claimant's Work Background</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">IRS SS-4</td>
|
|
<td><a class="bgi-none db" href="https://www.irs.gov/pub/irs-pdf/fss4.pdf" rel="noopener noreferrer" target="_blank">Application for Employer Identification Number</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/adultdisabilityreport/" rel="noopener noreferrer" target="_blank">Adult Disability Report</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://secure.ssa.gov/iApplsRe/start" rel="noopener noreferrer" target="_blank">Appeal a Recent Medical Decision</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/disabilityonline/" rel="noopener noreferrer" target="_blank">Apply for Disability Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/retireonline/" rel="noopener noreferrer" target="_blank">Apply for Retirement, Spouse's or Medicare Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/i1020/" rel="noopener noreferrer" target="_blank">Apply Online for Extra Help with Medicare Prescription Drug Plan Costs</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/faqs/en/questions/KA-01711.html" rel="noopener noreferrer" target="_blank">Change Address or Direct Deposit Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/childdisabilityreport/" rel="noopener noreferrer" target="_blank">Child Disability Report</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/faqs/en/questions/KA-01735.html" rel="noopener noreferrer" target="_blank">Get a Replacement Medicare Card</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/payee/form/" rel="noopener noreferrer" target="_blank">Representative Payee Accounting Report</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/faqs/en/questions/KA-01723.html" rel="noopener noreferrer" target="_blank">Request a Form SSA-1099/1042 (Benefit Statement) for tax or other purposes</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/myaccount/" rel="noopener noreferrer" target="_blank">Request a Proof of Social Security Benefits Letter</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/people/blind/" rel="noopener noreferrer" target="_blank">Request Special Notices for the Blind or Visually Impaired</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">Online</td>
|
|
<td><a class="bgi-none db" href="https://www.ssa.gov/myaccount/" rel="noopener noreferrer" target="_blank">Sign Up For or Change Direct Deposit</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-FS</td>
|
|
<td><a class="bgi-none db" href="ss-5fs.pdf" rel="noopener noreferrer" target="_blank">Application for a Social Security Card (Outside of the U.S.)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-SP</td>
|
|
<td><a class="bgi-none db" href="ss-5sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud para una tarjeta de Seguro Social</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-1-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Retirement Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-1-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud Para Beneficios De Seguro Por Jubliación</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-2-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Wife's or Husband's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-2-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud Para Beneficios De Seguro Como Cónyuge</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3</td>
|
|
<td><a class="bgi-none db" href="ssa-3.pdf" rel="noopener noreferrer" target="_blank">Marriage Certification</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-3sp.pdf" rel="noopener noreferrer" target="_blank">CERTIFICACION DE MATRIMONIO</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-4-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Child's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-4-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud Para Beneficios De Seguro Para Niños</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-4-inst.pdf" rel="noopener noreferrer" target="_blank">Reporting Responsibilities for Child's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-5-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Mother's or Father's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-5-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Application For Mother's Or Father's Insurance Benefits - Spanish</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-5-inst.pdf" rel="noopener noreferrer" target="_blank">Reporting Responsibilities for Mother's or Father's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-AR-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-ar-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Arabic</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-AM-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-am-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Armenian</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-CH-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-ch-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Chinese Traditional</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-CHS-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-chs-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Chinese Simplified</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-FA-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-fa-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Farsi</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-FR-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-fr-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - French</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-GR-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-gr-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Greek</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-HC-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-hc-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Haitian Creole</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-IT-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-it-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Italian</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-KOR-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-kor-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Korean</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-PE-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-pe-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Portuguese</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-PO-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-po-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Polish</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-RU-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-ru-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Russian</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-SO-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-so-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Instructional Guide for Completing the Application for a Social Security Card - Somali</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-TL-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-tl-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Taglog</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-UA-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-ua-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Ukraine</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SS-5-VI-INST</td>
|
|
<td><a class="bgi-none db" href="ss-5-vi-inst.pdf" rel="noopener noreferrer" target="_blank">Instructional Guide for Completing the Application for a Social Security Card - Vietnamese</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7-F6</td>
|
|
<td><a class="bgi-none db" href="ssa-7.pdf" rel="noopener noreferrer" target="_blank">Application for Parent's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7-F6-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-7-f6-sp.pdf" rel="noopener noreferrer" target="_blank">Application for Parent's Insurance Benefits - Spanish</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8</td>
|
|
<td><a class="bgi-none db" href="ssa-8.pdf" rel="noopener noreferrer" target="_blank">Application for Lump-Sum Death Payment</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8-SP</td>
|
|
<td><a class="bgi-none db" href="SSA-8-SP.pdf" rel="noopener noreferrer" target="_blank">SOLICITUD DEL PAGO GLOBAL POR DEFUNCIÓN</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-10</td>
|
|
<td><a class="bgi-none db" href="ssa-10.pdf" rel="noopener noreferrer" target="_blank">Application for Widow's or Widower's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-10-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-10-inst.pdf" rel="noopener noreferrer" target="_blank">Reporting Responsibilities for Widow's or Widower's Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-10-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-10-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud Para Beneficios de Seguro como Cónyuge Sobreviviente</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-16</td>
|
|
<td><a class="bgi-none db" href="ssa-16-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Disability Insurance Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-16-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-16-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud para beneficios de seguro por incapacidad</a></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-21</td>
|
|
<td><a class="bgi-none db" href="ssa-21.pdf" rel="noopener noreferrer" target="_blank">Supplement to Claim of Person Outside the United States</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-24</td>
|
|
<td><a class="bgi-none db" href="ssa-24.pdf" rel="noopener noreferrer" target="_blank">Application for Survivors Benefits (Payable Under Title II of the Social Security Act)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-25</td>
|
|
<td><a class="bgi-none db" href="ssa-25.pdf" rel="noopener noreferrer" target="_blank">Certification of Election for Reduced Spouse's Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-44</td>
|
|
<td><a class="bgi-none db" href="ssa-44.pdf" rel="noopener noreferrer" target="_blank">Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-88</td>
|
|
<td><a class="bgi-none db" href="ssa-88.pdf" rel="noopener noreferrer" target="_blank">Pre-Approval Form for Consent Based Social Security Number Verification (CBSV)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-89</td>
|
|
<td><a class="bgi-none db" href="ssa-89.pdf" rel="noopener noreferrer" target="_blank">Authorization for the Social Security Administration To Release Social Security Number (SSN) Verification</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-89-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-89-sp.pdf" rel="noopener noreferrer" target="_blank">Autorización para que la Administración de Seguro Social Divulgue la Verificación de un Número de Seguro Social (SSN)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-131</td>
|
|
<td><a class="bgi-none db" href="ssa-131.pdf" rel="noopener noreferrer" target="_blank">Employer Report of Special Wage Payments</a></td>
|
|
</tr>
|
|
<tr>
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<td class="va-t">SSA-150</td>
|
|
<td><a class="bgi-none db" href="ssa-150.pdf" rel="noopener noreferrer" target="_blank">Modified Benefits Formula Questionnaire</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-186</td>
|
|
<td><a class="bgi-none db" href="ssa-186.pdf" rel="noopener noreferrer" target="_blank">Temporary Institutionalization Statement to Maintain Household and Physician Certification</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-199</td>
|
|
<td><a class="bgi-none db" href="ssa-199.pdf" rel="noopener noreferrer" target="_blank">Vocational Rehabilitation Provider Claim</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-263</td>
|
|
<td><a class="bgi-none db" href="ssa-263.pdf" rel="noopener noreferrer" target="_blank">Waiver of Supplemental Security Income Payment Continuation</a></td>
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|
</tr>
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<tr>
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|
<td class="va-t">SSA-268</td>
|
|
<td><a class="bgi-none db" href="ssa-268.pdf" rel="noopener noreferrer" target="_blank">Patient Acknowledgement Form for Influenza Vaccination</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-295</td>
|
|
<td><a class="bgi-none db" href="ssa-295.pdf" rel="noopener noreferrer" target="_blank">Disability Determination Ready Claim Certification</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-308</td>
|
|
<td><a class="bgi-none db" href="ssa-308.pdf" rel="noopener noreferrer" target="_blank">Modified Benefits Formula Questionnaire, Foreign Pension</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-371</td>
|
|
<td><a class="bgi-none db" href="ssa-371.pdf" rel="noopener noreferrer" target="_blank">Request For Reinstatement - Title II</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-372</td>
|
|
<td><a class="bgi-none db" href="ssa-372.pdf" rel="noopener noreferrer" target="_blank">Request For Reinstatement - Title XVI</a></td>
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|
</tr>
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<tr>
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<td class="va-t">SSA-437-BK</td>
|
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<td><a class="bgi-none db" href="ssa-437.pdf" rel="noopener noreferrer" target="_blank">Complaint Form for Allegations of Discrimination in Programs or Activities Conducted by the Social Security Administration</a></td>
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</tr>
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<tr>
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<td class="va-t">SSA-437-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-437-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Formulario Para Querellas De Alegaciones De Discriminación En Los Programas De La Administración Del Seguro Social</a></td>
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|
</tr>
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<tr>
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<td class="va-t">SSA-454-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-454-bk.pdf" rel="noopener noreferrer" target="_blank">Continuing Disability Review Report</a></td>
|
|
</tr>
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|
<tr>
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|
<td class="va-t">SSA-455</td>
|
|
<td><a class="bgi-none db" href="ssa-455.pdf" rel="noopener noreferrer" target="_blank">Disability Update Report</a></td>
|
|
</tr>
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|
<tr>
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|
<td class="va-t">SSA-521</td>
|
|
<td><a class="bgi-none db" href="ssa-521.pdf" rel="noopener noreferrer" target="_blank">Request for Withdrawal of Application</a></td>
|
|
</tr>
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<tr>
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|
<td class="va-t">SSA-521-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-521-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud Para Revocar Una Reclamación</a></td>
|
|
</tr>
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<tr>
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|
<td class="va-t">SSA-545-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-545.html" rel="noopener noreferrer" target="_blank">Plan for Achieving Self-Support</a></td>
|
|
</tr>
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|
<tr>
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|
<td class="va-t">SSA-546</td>
|
|
<td><a class="bgi-none db" href="ssa-546.pdf" rel="noopener noreferrer" target="_blank">Worker's Compensation/Public Disability Questionnaire</a></td>
|
|
</tr>
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<tr>
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<td class="va-t">SSA-552</td>
|
|
<td><a class="bgi-none db" href="ssa-552.pdf" rel="noopener noreferrer" target="_blank">Dedicated Account Use of Funds Statement</a></td>
|
|
</tr>
|
|
<tr>
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|
<td class="va-t">SSA-561</td>
|
|
<td><a class="bgi-none db" href="ssa-561.html" rel="noopener noreferrer" target="_blank">Request for Reconsideration</a></td>
|
|
</tr>
|
|
<!--
|
|
<tr>
|
|
<td class="va-t">SSA-581-OP252</td>
|
|
<td><a class="bgi-none db" href="ssa-581-op252.pdf" rel="noopener noreferrer" target="_blank">Authorization to Obtain Earnings Data from the Social Security Administration</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-581-OP253</td>
|
|
<td><a class="bgi-none db" href="ssa-581-op253.pdf" rel="noopener noreferrer" target="_blank">Authorization to Obtain Earnings Data from the Social Security Administration</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-581-OP258</td>
|
|
<td><a class="bgi-none db" href="ssa-581-op258.pdf" rel="noopener noreferrer" target="_blank">Authorization to Obtain Earnings Data from the Social Security Administration </a></td>
|
|
</tr>
|
|
-->
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-604</td>
|
|
<td><a class="bgi-none db" href="ssa-604.pdf" rel="noopener noreferrer" target="_blank">Certificate of Incapacity</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-632-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-632-bk.pdf" rel="noopener noreferrer" target="_blank">Request for Waiver of Overpayment Recovery</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-632-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-632-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud de exoneración de sobrepago</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-634</td>
|
|
<td><a class="bgi-none db" href="ssa-634.pdf" rel="noopener noreferrer" target="_blank">Request for Change in Overpayment Recovery Rate</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-634-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-634-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud de cambio en la tasa de recuperación de sobrepago</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-640</td>
|
|
<td><a class="bgi-none db" href="ssa-640.pdf" rel="noopener noreferrer" target="_blank">Financial Disclosure for Civil Monetary Penatly (CMP) Debt</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-671</td>
|
|
<td><a class="bgi-none db" href="ssa-671.pdf" rel="noopener noreferrer" target="_blank">Railroad Employment Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-711</td>
|
|
<td><a class="bgi-none db" href="ssa-711.pdf" rel="noopener noreferrer" target="_blank">Request for Deceased Individual's Social Security Record</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-714</td>
|
|
<td><a class="bgi-none db" href="ssa-714.pdf" rel="noopener noreferrer" target="_blank">You can make your payment by Credit Card</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-721</td>
|
|
<td><a class="bgi-none db" href="ssa-721.pdf" rel="noopener noreferrer" target="_blank">Statement of Death by Funeral Director</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-731</td>
|
|
<td><a class="bgi-none db" href="ssa-731.pdf" rel="noopener noreferrer" target="_blank">Notice to Electronic Information Exchange Partners to Provide Contractor List</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-753</td>
|
|
<td><a class="bgi-none db" href="ssa-753.pdf" rel="noopener noreferrer" target="_blank">Statement Regarding Marriage</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-760</td>
|
|
<td><a class="bgi-none db" href="ssa-760.pdf" rel="noopener noreferrer" target="_blank">Certificate of Support</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-765</td>
|
|
<td><a class="bgi-none db" href="ssa-765.pdf" rel="noopener noreferrer" target="_blank">Response to Notice of Revised Determination</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-766</td>
|
|
<td><a class="bgi-none db" href="ssa-766.pdf" rel="noopener noreferrer" target="_blank">Statement of Self-Employment Income</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-754-F5</td>
|
|
<td><a class="bgi-none db" href="ssa-754-f5.pdf" rel="noopener noreferrer" target="_blank">Statement of Marital Relationship</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-769</td>
|
|
<td><a class="bgi-none db" href="ssa-769-u4.pdf" rel="noopener noreferrer" target="_blank">Request for Change in Time/Place of Disability Hearing</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-770-U4</td>
|
|
<td><a class="bgi-none db" href="ssa-770-u4.pdf" rel="noopener noreferrer" target="_blank">Notice Regarding Substitution of Party Upon Death of Claimant Reconsideration of Disability Cessation</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-773</td>
|
|
<td><a class="bgi-none db" href="ssa-773-u4.pdf" rel="noopener noreferrer" target="_blank">Waiver Of Right To Appear - Disability Hearing</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-781</td>
|
|
<td><a class="bgi-none db" href="ssa-781.pdf" rel="noopener noreferrer" target="_blank">Certificate of Responsibility for Welfare and Care of Child</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-783</td>
|
|
<td><a class="bgi-none db" href="ssa-783.pdf" rel="noopener noreferrer" target="_blank">Statement Regarding Contributions</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-788</td>
|
|
<td><a class="bgi-none db" href="ssa-788.pdf" rel="noopener noreferrer" target="_blank">Statement of Care and Responsibility for Beneficiary</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-789</td>
|
|
<td><a class="bgi-none db" href="ssa-789.pdf" rel="noopener noreferrer" target="_blank">Request for Reconsideration - Disability Cessation</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-795</td>
|
|
<td><a class="bgi-none db" href="ssa-795.pdf" rel="noopener noreferrer" target="_blank">Statement of Claimant or Other Persons</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-795-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-795-sp.pdf" rel="noopener noreferrer" target="_blank">Statement of Claimant or Other Persons (Spanish)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-820-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-820.pdf" rel="noopener noreferrer" target="_blank">Work Activity Report (Self-Employed Person)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-821-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-821.pdf" rel="noopener noreferrer" target="_blank">Work Activity Report</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-827-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-827-inst.pdf" rel="noopener noreferrer" target="_blank">Instructions for Completing the SSA-827</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-827-INST-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-827-inst-sp.pdf" rel="noopener noreferrer" target="_blank">Instrucciones para completar el formulario SSA-827</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1020</td>
|
|
<td><a class="bgi-none db" href="ssa-1020.html" rel="noopener noreferrer" target="_blank">SSA-1020 Forms</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1020-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-1020-ocr-sm-inst.pdf" rel="noopener noreferrer" target="_blank">General Instructions for Completing the Application for Extra Help with Medicare Prescription Drug Plan Costs</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1021</td>
|
|
<td><a class="bgi-none db" href="ssa-1021.pdf" rel="noopener noreferrer" target="_blank">Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1021-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-1021-sp.pdf" rel="noopener noreferrer" target="_blank">Apelación de la determinación para recibir el Beneficio Adicional con los gastos del plan de medicamentos recetados de Medicare</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1021-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-1021-inst.pdf" rel="noopener noreferrer" target="_blank">Instructions for Completing the Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1021-INST-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-1021-inst-sp.pdf" rel="noopener noreferrer" target="_blank">Instrucciones para llenar la apelación de la determinación para recibir el beneficio adicional con los gastos del plan de medicamentos recetados de Medicare</a></td>
|
|
</tr>
|
|
<!-- <tr>
|
|
<td class="va-t">SSA-1026B-OCR-SM-INST</td>
|
|
<td><a class="bgi-none db" href="ssa-1026b-ocr-sm-inst.pdf" rel="noopener noreferrer" target="_blank">Review of your Eligibility for Extra Help</a></td>
|
|
</tr> -->
|
|
<!-- <tr>
|
|
<td class="va-t">SSA-1026B-OCR-SM-INST-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-1026b-ocr-sm-sp-inst.pdf" rel="noopener noreferrer" target="_blank">Revisión sobre su derecho a recibir el Beneficio Adicional</a></td>
|
|
</tr> -->
|
|
<tr>
|
|
<td class="va-t">SSA-1199</td>
|
|
<td><a class="bgi-none db" href="ssa-1199.html">International Direct Deposit (IDD)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1372-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-1372.pdf" rel="noopener noreferrer" target="_blank">Advanced Notice of Termination of Child's Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1372-BK-FC</td>
|
|
<td><a class="bgi-none db" href="ssa-1372bkfc.pdf" rel="noopener noreferrer" target="_blank">Advanced Notice of Termination of Child's Benefits (Foreign Claims)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1372-BK-FC-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-1372-bk-fc-sp.pdf" rel="noopener noreferrer" target="_blank">Adviso Por Adelantado De Cese De Beneficios Para Niños</a></td>
|
|
</tr>
|
|
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-1383</td>
|
|
<td><a class="bgi-none db" href="ssa-1383.pdf" rel="noopener noreferrer" target="_blank">Student Reporting Form</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1383-FC</td>
|
|
<td><a class="bgi-none db" href="ssa-1383-fc.pdf" rel="noopener noreferrer" target="_blank">Reporting to Social Security Administration by Student Outside the United States</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1391</td>
|
|
<td><a class="bgi-none db" href="ssa-1391.pdf" rel="noopener noreferrer" target="_blank">Employment Network Payment Request Form</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1414</td>
|
|
<td><a class="bgi-none db" href="ssa-1414.pdf" rel="noopener noreferrer" target="_blank">Credit Card Payment Form</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1458</td>
|
|
<td><a class="bgi-none db" href="ssa-1458.pdf" rel="noopener noreferrer" target="_blank">Certification By Religious Group</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1560</td>
|
|
<td><a class="bgi-none db" href="ssa-1560.pdf" rel="noopener noreferrer" target="_blank">Petition For Authorization To Charge And Collect A Fee For Services Before The Social Security Administration</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1691</td>
|
|
<td><a class="bgi-none db" href="ssa-1691.pdf" rel="noopener noreferrer" target="_blank">Eligible Non-Attorney Representative Application</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1693</td>
|
|
<td><a class="bgi-none db" href="ssa-1693.pdf" rel="noopener noreferrer" target="_blank">Fee Agreement for Representation Before the Social Security Administration</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1694</td>
|
|
<td><a class="bgi-none db" href="ssa-1694.pdf" rel="noopener noreferrer" target="_blank">Request for Business Entity Taxpayer Information</a></td>
|
|
</tr>
|
|
<!--<tr>
|
|
<td class="va-t">SSA-1695-F3</td>
|
|
<td><a class="bgi-none db" href="ssa-1695.pdf" rel="noopener noreferrer" target="_blank">Identifying Information for Possible Direct Payment of Authorized Fees</a></td>
|
|
</tr>-->
|
|
<tr>
|
|
<td class="va-t">SSA-1696</td>
|
|
<td><a class="bgi-none db" href="ssa-1696.pdf" rel="noopener noreferrer" target="_blank">Claimant's Appointment of Representative</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1696-SUP1</td>
|
|
<td><a class="bgi-none db" href="ssa-1696-sup1.pdf" rel="noopener noreferrer" target="_blank">Claimant's Revocation of the Appointment of a Representative</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1696-SUP2</td>
|
|
<td><a class="bgi-none db" href="ssa-1696-sup2.pdf" rel="noopener noreferrer" target="_blank">Representative's Withdrawal of Acceptance of Appointment</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1699</td>
|
|
<td><a class="bgi-none db" href="ssa-1699.pdf" rel="noopener noreferrer" target="_blank">Registration for Appointed Representative Services and Direct Payment</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1724-F4</td>
|
|
<td><a class="bgi-none db" href="ssa-1724.html" rel="noopener noreferrer" target="_blank">Claim for Amounts due in case of a Deceased Beneficiary</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-1945</td>
|
|
<td><a class="bgi-none db" href="ssa-1945.pdf" rel="noopener noreferrer" target="_blank">Statement Concerning Your Employment in a Job Not Covered by Social Security</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2010</td>
|
|
<td><a class="bgi-none db" href="ssa-2010-f6.pdf" rel="noopener noreferrer" target="_blank">Statement for Determining Continuing Entitlement for Special Veterans Benefits (SVB)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2032-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-2032bk.pdf" rel="noopener noreferrer" target="_blank">Request for Waiver of Special Veterans Benefits (SVB) Overpayment Recovery or Change in Repayment Rate</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2490</td>
|
|
<td><a class="bgi-none db" href="ssa-2490-bk.pdf" rel="noopener noreferrer" target="_blank">Application For Benefits Under a U.S. International Social Security Agreement</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2512</td>
|
|
<td><a class="bgi-none db" href="ssa-2512.pdf" rel="noopener noreferrer" target="_blank">Pre-1957 Military Service Federal Benefit Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2519</td>
|
|
<td><a class="bgi-none db" href="ssa-2519.pdf" rel="noopener noreferrer" target="_blank">Child Relationship Statement</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2574</td>
|
|
<td><a class="bgi-none db" href="ssa-2574.pdf" rel="noopener noreferrer" target="_blank">Information About Joint Checking/Savings Accounts Supplemental Security Income</a></td>
|
|
</tr>
|
|
<!-- <tr>
|
|
<td class="va-t">SSA-2853-OP4</td>
|
|
<td><a class="bgi-none db" href="ssa-2853-op4.pdf" rel="noopener noreferrer" target="_blank">Message From Social Security - 10 Weeks</a></td>
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|
</tr> -->
|
|
<tr>
|
|
<td class="va-t">SSA-2855</td>
|
|
<td><a class="bgi-none db" href="ssa-2855.pdf" rel="noopener noreferrer" target="_blank">Statement of Funds you Received</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-2935</td>
|
|
<td><a class="bgi-none db" href="ssa-2935.pdf" rel="noopener noreferrer" target="_blank">Authorization to the Social Security Administration to Obtain Personal Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3033</td>
|
|
<td><a class="bgi-none db" href="ssa-3033.pdf" rel="noopener noreferrer" target="_blank">Employee Work Activity Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3105</td>
|
|
<td><a class="bgi-none db" href="ssa-3105.pdf" rel="noopener noreferrer" target="_blank">Important information about your appeal, waiver rights, and repayment options</a></td>
|
|
</tr>
|
|
<!--<tr> -- form retired on 9.15.21
|
|
<td class="va-t">SSA-3194</td>
|
|
<td><a class="bgi-none db" href="ssa-3194.pdf" rel="noopener noreferrer" target="_blank">Permanent Medical Parking Renewal Certification</a></td>
|
|
</tr>-->
|
|
<tr>
|
|
<td class="va-t">SSA-3288</td>
|
|
<td><a class="bgi-none db" href="ssa-3288.pdf" rel="noopener noreferrer" target="_blank">Consent for Release of Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3288-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-3288-sp.pdf" rel="noopener noreferrer" target="_blank">Consentimiento para divulgar información</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3368-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3368-bk.pdf" rel="noopener noreferrer" target="_blank">Disability Report - Adult</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3369-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3369.pdf" rel="noopener noreferrer" target="_blank">Work History Report</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3373-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3373-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Adult</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3375-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3375-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Child Birth to 1st Birthday</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3376-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3376-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Child Age 1 to 3rd Birthday</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3377-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3377-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Child Age 3 to 6th Birthday</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3378-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3378-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Child Age 6 to 12th Birthday</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3379-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3379-bk.pdf" rel="noopener noreferrer" target="_blank">Function Report - Child Age 12 to 18th Birthday</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3380-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3380.pdf" rel="noopener noreferrer" target="_blank">Function Report - Adult - Third Party Form</a></td>
|
|
</tr>
|
|
<!-- <tr>
|
|
<td class="va-t">SSA-3381</td>
|
|
<td><a class="bgi-none db" href="ssa-3381.pdf" rel="noopener noreferrer" target="_blank">Medical and Job Worksheet - Adult</a></td>
|
|
</tr> -->
|
|
<tr>
|
|
<td class="va-t">SSA-3441-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3441.html" rel="noopener noreferrer" target="_blank">Disability Report - Appeal</a></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-3830</td>
|
|
<td><a class="bgi-none db" href="ssa-3830.pdf" rel="noopener noreferrer" target="_blank">Certification of Low Birth Weight for SSI Eligibility</a></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-3881-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-3881.pdf" rel="noopener noreferrer" target="_blank">Questionnaire for Children Claiming SSI Benefits</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-3885</td>
|
|
<td><a class="bgi-none db" href="ssa-3885.pdf" rel="noopener noreferrer" target="_blank">Government Pension Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4111</td>
|
|
<td><a class="bgi-none db" href="ssa-4111.pdf" rel="noopener noreferrer" target="_blank">Certification of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits</a></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="va-t">SSA-4162</td>
|
|
<td><a class="bgi-none db" href="ssa-4162.pdf" rel="noopener noreferrer" target="_blank">Child Care Dropout Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4178</td>
|
|
<td><a class="bgi-none db" href="ssa-4178.pdf" rel="noopener noreferrer" target="_blank">Marital Relationship Questionaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4814</td>
|
|
<td><a class="bgi-none db" href="ssa-4814.pdf" rel="noopener noreferrer" target="_blank">Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-4815</td>
|
|
<td><a class="bgi-none db" href="ssa-4815.pdf" rel="noopener noreferrer" target="_blank">Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5062</td>
|
|
<td><a class="bgi-none db" href="ssa-5062.pdf" rel="noopener noreferrer" target="_blank">Claimant's Statement about Loan of Food or Shelter</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5064</td>
|
|
<td><a class="bgi-none db" href="ssa-5064.pdf" rel="noopener noreferrer" target="_blank">Claimant's Statement About Loan For Shelter</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5665-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-5665-bk.pdf" rel="noopener noreferrer" target="_blank">Teacher Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5665-BK-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-5665-bk-sp.pdf" rel="noopener noreferrer" target="_blank">Cuestionario para Maestros (Teacher Questionnaire)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-5666</td>
|
|
<td><a class="bgi-none db" href="ssa-5666.pdf" rel="noopener noreferrer" target="_blank">Request for Administrative Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7004</td>
|
|
<td><a class="bgi-none db" href="ssa-7004.pdf" rel="noopener noreferrer" target="_blank">Request for Social Security Statement</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7004-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-7004-sp.pdf" rel="noopener noreferrer" target="_blank">Solicitud para un Estado de cuenta del Seguro Social</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7008</td>
|
|
<td><a class="bgi-none db" href="ssa-7008.pdf" rel="noopener noreferrer" target="_blank">Request for Correction of Earnings Record</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7011-F4</td>
|
|
<td><a class="bgi-none db" href="ssa-7011-f4.pdf" rel="noopener noreferrer" target="_blank">Statement of Employer</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7050-F4</td>
|
|
<td><a class="bgi-none db" href="ssa-7050.pdf" rel="noopener noreferrer" target="_blank">Request for Social Security Earnings Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7104</td>
|
|
<td><a class="bgi-none db" href="ssa-7104.pdf" rel="noopener noreferrer" target="_blank">Partnership Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7156</td>
|
|
<td><a class="bgi-none db" href="ssa-7156.pdf" rel="noopener noreferrer" target="_blank">Farm Self Employment Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7157-F4</td>
|
|
<td><a class="bgi-none db" href="ssa-7157.pdf" rel="noopener noreferrer" target="_blank">Farm Arrangement Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7160</td>
|
|
<td><a class="bgi-none db" href="ssa-7160.pdf" rel="noopener noreferrer" target="_blank">Employment Relationship Questionnaire</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7163</td>
|
|
<td><a class="bgi-none db" href="ssa-7163.pdf" rel="noopener noreferrer" target="_blank">Questionnaire about Employment or Self Employment</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-7163A</td>
|
|
<td><a class="bgi-none db" href="ssa-7163a.pdf" rel="noopener noreferrer" target="_blank">Supplemental Statement Regarding Farming Activities</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8000-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-8000-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Supplemental Security Income (SSI)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8001-BK</td>
|
|
<td><a class="bgi-none db" href="ssa-8001-bk.pdf" rel="noopener noreferrer" target="_blank">Application for Supplemental Security Income (SSI) (Deferred or Abbreviated)</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8240</td>
|
|
<td><a class="bgi-none db" href="ssa-8240.pdf" rel="noopener noreferrer" target="_blank">Authorization for the Social Security Administration to Obtain Wage and Employment Information from Payroll Data Providers</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8510</td>
|
|
<td><a class="bgi-none db" href="ssa-8510.pdf" rel="noopener noreferrer" target="_blank">Authorization for the Social Security Administration to Obtain Personal Information</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-8552</td>
|
|
<td><a class="bgi-none db" href="ssa-8552.pdf" rel="noopener noreferrer" target="_blank">Interview Confirmation</a></td>
|
|
</tr>
|
|
<tr>
|
|
<!-- <td class="va-t">SSA-L447</td>
|
|
<td><a class="bgi-none db" href="ssa-l447.pdf" rel="noopener noreferrer" target="_blank">Medicare Savings Programs Eligible Letters</a></td>
|
|
</tr>
|
|
<tr>
|
|
<td class="va-t">SSA-L447-SP</td>
|
|
<td><a class="bgi-none db" href="ssa-l447-sp.pdf" rel="noopener noreferrer" target="_blank">Cartas para saber si tiene derecho al Programa de ahorros de Medicare</a></td>
|
|
</tr>-->
|
|
</tbody>
|
|
</table>
|
|
</section>
|
|
</section>
|
|
</section>
|
|
</article>
|
|
|
|
<!-- CELL -->
|
|
<aside class="l-cell l-w-30">
|
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<h3 class="by">Related Information</h3>
|
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<ul>
|
|
<li><a href="/benefits/forms/">Apply for Benefits</a></li>
|
|
<li><a href="thirdpartyforms.html">Third Party Organizations</a></li>
|
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</ul>
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</aside>
|
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</div>
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</section>
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