SSI Application Form

Download SSI Application here. All forms are FREE. 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 1-800-772-1213 (TTY 1-800-325-0778) or contact your local Social Security office and we will help you. If you download, print and complete a paper form, please mail or take it to your local Social Security office or the office that requested it from you.

Below are some of the SSI Forms.

NumberTitle
SS-5Application for a Social Security CardIn some areas, you may request a replacement Social Security card online.
SSA-827Authorization to Disclose Information to the Social Security Administration
SSA-3820-BKDisability Report – Child
IRS W-4VVoluntary Withholding Request
CMS-40BApplication for Enrollment in Medicare – Part B (Medical Insurance)
CMS-L564Request for Employment Information
CMS-L564SSolicitud De Información Sobre El Empleo
HA-85Request to Withdraw a Hearing Request
HA-86Discontinue Prior Editions
HA-501-U5Request for Hearing by Administrative Law Judge
HA-520-U5Request for Review of Hearing Decision/Order
HA-539Notice Regarding Substitution of Party Upon Death of Claimant
HA-539-SPAviso Sobre La Substitución De La Parte Interesada Tras El Fallecimiento Del Reclamante
HA-4608Waiver of Your Right to Personal Appearance Before an Administrative Law Judge
HA-4631Claimant’s Recent Medical Treatment
HA-4632Claimant’s Medications
HA-4633Claimant’s Work Background
IRS SS-4Application for Employer Identification Number
OnlineAdult Disability Report
OnlineAppeal a Recent Medical Decision
OnlineApply for Disability Benefits
OnlineApply for Retirement, Spouse’s or Medicare Benefits
OnlineApply Online for Extra Help with Medicare Prescription Drug Plan Costs
OnlineChange Address or Telephone Number
OnlineChild Disability Report
OnlineGet a Replacement Medicare Card
OnlineRepresentative Payee Accounting Report
OnlineRequest a Form SSA-1099/1042 (Benefit Statement) for tax or other purposes
OnlineRequest a Proof of Social Security Benefits Letter
OnlineRequest Special Notices for the Blind or Visually Impaired
OnlineSign Up For or Change Direct Deposit
SS-5-FSApplication for a Social Security Card (Outside of the U.S.)
SS-5-SPSolicitud para una tarjeta de Seguro Social
SSA-1-BKApplication for Retirement Insurance Benefits
SSA-1-BK-SPSolicitud Para Beneficios De Seguro Por Jubliación
SSA-2-BKApplication for Wife’s or Husband’s Insurance Benefits
SSA-2-BK-SPSolicitud Para Beneficios De Seguro Como Cónyuge
SSA-3Marriage Certification
SSA-4-BKApplication for Child’s Insurance Benefits
SSA-4-BK-SPSolicitud Para Beneficios De Seguro Para Niños
SSA-4-INSTReporting Responsibilities for Child’s Insurance Benefits
SSA-5-BKApplication for Mother’s or Father’s Insurance Benefits
SSA-5-BK-SPApplication For Mother’s Or Father’s Insurance Benefits – Spanish
SSA-5-INSTReporting Responsibilities for Mother’s or Father’s Insurance Benefits
SSA-7-F6Application for Parent’s Insurance Benefits
SSA-7-F6-SPApplication for Parent’s Insurance Benefits – Spanish
SSA-8Application for Lump-Sum Death Payment
SSA-8-SPSOLICITUD DEL PAGO GLOBAL POR DEFUNCIÓN
SSA-10Application for Widow’s or Widower’s Insurance Benefits
SSA-10-INSTReporting Responsibilities for Widow’s or Widower’s Insurance Benefits
SSA-16Application for Disability Insurance Benefits
SSA-16-SPSolicitud para beneficios de seguro por incapacidad
SSA-16-INSTReporting Responsibilities For Disability Insurance Benefits
SSA-21Supplement to Claim of Person Outside the United States
SSA-24Application for Survivors Benefits (Payable Under Title II of the Social Security Act)
SSA-25Certification of Election for Reduced Spouse’s Benefits
SSA-44Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event
SSA-88Pre-Approval Form for Consent Based Social Security Number Verification (CBSV)
SSA-89Authorization for the Social Security Administration To Release Social Security Number (SSN) Verification
SSA-89-SPAutorización para que la Administración de Seguro Social Divulgue la Verificación de un Número de Seguro Social (SSN)
SSA-131Employer Report of Special Wage Payments
SSA-150Modified Benefits Formula Questionnaire
SSA-199Vocational Rehabilitation Provider Claim
SSA-263Waiver of Supplemental Security Income Payment Continuation
SSA-308Modified Benefits Formula Questionnaire, Foreign Pension
SSA-437-BKComplaint Form for Allegations of Discrimination in Programs or Activities Conducted by the Social Security Administration
SSA-437-BK-SPFormulario Para Querellas De Alegaciones De Discriminación En Los Programas De La Administración Del Seguro Social
SSA-454-BKContinuing Disability Review Report
SSA-521Request for Withdrawal of Application
SSA-521-SPSolicitud Para Revocar Una Reclamación
SSA-545-BKPlan for Achieving Self-Support
SSA-546Worker’s Compensation/Public Disability Questionnaire
SSA-561-U2Request for Reconsideration
SSA-604Certificate of Incapacity
SSA-632-BKRequest for Waiver of Overpayment Recovery
SSA-634Request for Change in Overpayment Recovery Rate
SSA-634-SPSolicitud de cambio en la tasa de recuperación de sobrepago
SSA-640Financial Disclosure for Civil Monetary Penatly (CMP) Debt
SSA-671Railroad Employment Questionnaire
SSA-711Request for Deceased Individual’s Social Security Record
SSA-714You can make your payment by Credit Card
SSA-721Statement of Death by Funeral Director
SSA-731Notice to Electronic Information Exchange Partners to Provide Contractor List
SSA-753Statement Regarding Marriage
SSA-754-F5Statement of Marital Relationship
SSA-769-U4Request for Change in Time/Place of Disability Hearing
SSA-770-U4Notice Regarding Substitution of Party Upon Death of Claimant Reconsideration of Disability Cessation
SSA-773-U4Waiver Of Right To Appear – Disability Hearing
SSA-781Certificate of Responsibility for Welfare and Care of Child
SSA-783Statement Regarding Contributions
SSA-788Statement of Care and Responsibility for Beneficiary
SSA-789-U4Request for Reconsideration – Disability Cessation
SSA-795Statement of Claimant or Other Persons
SSA-820-BKWork Activity Report (Self-Employed Person)
SSA-821-BKWork Activity Report
SSA-827-INSTInstructions for Completing the SSA-827
SSA-827-INST-SPInstrucciones para completar el formulario SSA-827
SSA-1020-INSTGeneral Instructions for Completing the Application for Extra Help with Medicare Prescription Drug Plan Costs
SSA-1021Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs
SSA-1021-SPApelación de la determinación para recibir el Beneficio Adicional con los gastos del plan de medicamentos recetados de Medicare
SSA-1021-INSTInstructions for Completing the Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs
SSA-1021-INST-SPInstrucciones para llenar la apelación de la determinación para recibir el beneficio adicional con los gastos del plan de medicamentos recetados de Medicare
SSA-1199International Direct Deposit (IDD)
SSA-1372-BKAdvanced Notice of Termination of Child’s Benefits
SSA-1372-BK-FCAdvanced Notice of Termination of Child’s Benefits (Foreign Claims)
SSA-1372-BK-FC-SPAdviso Por Adelantado De Cese De Beneficios Para Niños
SSA-1383Student Reporting Form
SSA-1383-FCReporting to Social Security Administration by Student Outside the United States
SSA-1414Credit Card Payment Form
SSA-1458Certification By Religious Group
SSA-1560Petition For Authorization To Charge And Collect A Fee For Services Before The Social Security Administration
SSA-1691Eligible Non-Attorney Representative Application
SSA-1693Fee Agreement for Representation Before the Social Security Administration
SSA-1694Request for Business Entity Taxpayer Information
SSA-1696Claimant’s Appointment of Representative
SSA-1696-SUP1Claimant’s Revocation of the Appointment of a Representative
SSA-1696-SUP2Representative’s Withdrawal of Acceptance of Appointment
SSA-1699Registration for Appointed Representative Services and Direct Payment
SSA-1724-F4Claim for Amounts due in case of a Deceased Beneficiary
SSA-1945Statement Concerning Your Employment in a Job Not Covered by Social Security
SSA-2010-F6Statement for Determining Continuing Entitlement for Special Veterans Benefits (SVB)
SSA-2032-BKRequest for Waiver of Special Veterans Benefits (SVB) Overpayment Recovery or Change in Repayment Rate
SSA-2512Pre-1957 Military Service Federal Benefit Questionnaire
SSA-2519Child Relationship Statement
SSA-2855Statement of Funds you Received
SSA-3033Employee Work Activity Questionnaire
SSA-3105Important information about your appeal, waiver rights, and repayment options
SSA-3288Consent for Release of Information
SSA-3288-SPConsentimiento para divulgar información
SSA-3368-BKDisability Report – Adult
SSA-3369-BKWork History Report
SSA-3373-BKFunction Report – Adult
SSA-3375-BKFunction Report – Child Birth to 1st Birthday
SSA-3376-BKFunction Report – Child Age 1 to 3rd Birthday
SSA-3377-BKFunction Report – Child Age 3 to 6th Birthday
SSA-3378-BKFunction Report – Child Age 6 to 12th Birthday
SSA-3379-BKFunction Report – Child Age 12 to 18th Birthday
SSA-3380-BKFunction Report – Adult – Third Party Form
SSA-3441-BKDisability Report – Appeal
SSA-3881-BKQuestionnaire for Children Claiming SSI Benefits
SSA-3885Government Pension Questionnaire
SSA-4111Certification of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
SSA-4162Child Care Dropout Questionnaire
SSA-4814Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection
SSA-4815Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection
SSA-5062Claimant’s Statement about Loan of Food or Shelter
SSA-5665-BKTeacher Questionnaire
SSA-5665-BK-SPCuestionario para Maestros (Teacher Questionnaire)
SSA-5666Request for Administrative Information
SSA-7004Request for Social Security Statement
SSA-7008Request for Correction of Earnings Record
SSA-7050-F4Request for Social Security Earnings Information
SSA-7104Partnership Questionnaire
SSA-7156Farm Self Employment Questionnaire
SSA-7157-F4Farm Arrangement Questionnaire
SSA-7160Employment Relationship Questionnaire
SSA-7163Questionnaire about Employment or Self Employment
SSA-7163A-F4Supplemental Statement Regarding Farming Activities
SSA-8240Authorization for the Social Security Administration to Obtain Wage and Employment Information from Payroll Data Providers
SSA-8510Authorization for the Social Security Administration to Obtain Personal Information
SSA-L447Medicare Savings Programs Eligible Letters
SSA-L447-SPCartas para saber si tiene derecho al Programa de ahorros de Medicare

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