Ssa3368 Bk 2020

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Disability Report- Adult-Form SSA-3368-BK You can get help from other people such as a friend or family member. DISABILITY REPORT - ADULT 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. Completing this report accurately and completely will help us expedite your claim. Please complete as much of the report as you can. IF YOU NEED HELP Note If you are assisting someone else with this report please answer the questions as if that person were completing the report. Send only comments relating to our time estimate to this address not the completed form. AFTER COMPLETING THIS REPORT REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS Form Approved OMB No. 0960-0579 For SSA Use Only- Do not write in this box. Related SSN SOCIAL SECURITY ADMINISTRATION ADULT Number Holder Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment commits a crime punishable under Federal law by fine imprisonment or both and may be subject to administrative sanctions. If you are filling out this report for someone else please provide information about him or her. When a question refers to you or your it refers to the person who is applying for disability benefits. If you are filling out this report for someone else please provide information about him or her. When a question refers to you or your it refers to the person who is applying for disability benefits. SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON 1. B. Social Security Number 1. A. Name First Middle Initial Last 1. F. Who is completing this report The person who is applying for disability. Go to Section 3 - Medical Conditions The person listed in 2. A. Go to Section 3 - Medical Conditions Someone else Complete the rest of Section 2 below 2. G. Name First Middle Initial Last 2. SECTION 9 - OTHER MEDICAL INFORMATION 9. Does anyone else have medical information about your physical and/or mental condition s including emotional and compensation vocational rehabilitation insurance companies who have paid you disability benefits prisons attorneys social service agencies and welfare. Yes Please complete the information below. No If you are receiving Supplemental Security Income SSI and have been asked to complete this report go to Section 10 - Vocational Rehabilitation if not go to Section 11 on the last page. If you have an appointment please have the completed report ready when we contact you. If we ask you to do so please mail the completed report to us ahead of time. WHAT WE MEAN BY DISABILITY Disability under Social Security is based on your inability to work. 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. If yes please list them here SECTION 2 - CONTACTS Give the name of someone other than your doctors we can contact who knows about your medical conditions and can help you with your claim. 2. B. Relationship to you 2. C. Daytime Phone Number as described in 1. E. above 2. E. Can this person speak and understand English Destroy Prior Editions Page 1 2. F. Who is completing this report The person who is applying for disability. Go to Section 3 - Medical Conditions The person listed in 2.

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VersionsForm popularityFillable & printable
SSA-3368-BK 20204.8 Satisfied (3268 Votes)
SSA-3368-BK 20154.8 Satisfied (2105 Votes)
SSA-3368-BK 20124.6 Satisfied (493 Votes)
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How to create an eSignature for the ssa3368 bk

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