Apply Online – SSDI APPLY

1Personal Information

2Citizenship

3Marriage Information

4Other Information

5Payment

Personal Information

First Name*

Middle Name

Last Name*

Enter your Social Security Number*

Is English your preferred Language?*

Yes

Enter the language you prefer to speak:*

Enter the language you prefer to write:*

Enter your date of birth*

Month

Day

Year

Enter name of city and state or foreign country where you were born*

City State / Province / Region ZIP / Postal Code Country

Citizenship

Are you a U.S. citizen?*

Yes

Are you an alien lawfully present in the U.S.?*

Yes

When were you lawfully admitted to the U.S.?*

Was your name different at birth?*

Yes

Enter your name at birth if different*

Have you used any other names?*

Yes

Other name(s) used.*

Have you used any other Social Security number(s)?*

Yes

Enter Social Security number(s) used.*

When do you believe your condition(s) became severe enough to keep you from working (even if you have never worked)?*

Did you or your spouse (or prior spouse) work in the railroad industry for 5 years or more?*

Yes

Do you have Social Security credits (for example, based on work or residence) under another country's Social Security System?*

Yes

List the country(ies):*

Are you entitled to, or do you expect to be entitled to, a pension or annuity (or a lump sum in place of a pension or annuity) based on your work after 1956 not covered by Social Security?*

Yes

I became entitled, or expect to become entitled, beginning*

I became entitled, or expect to become entitled, beginning

Date*

Month

Day

Year

Marriage Information

Have you ever been married?*

Yes

Give the following information about your current marriage. If not currently married,

Spouse's name (including maiden name)*

When*

Month

Day

Year

City*

State*

Marriage performed by:*

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth (or age)*

Day

Month

Year

Spouse's Social Security Number (If none or unknown, so indicate)*

Other Marriage Information

Enter information about any other marriage if you:*

Had a marriage that lasted at least 10 years; or
Had a marriage that ended due to the death of your spouse, regardless of duration; or
Were divorced, remarried the same individual within the year immediately following the year of the divorce, and the combined period of marriage totaled 10 years or more. If none, write "None." Go on to item 12 (d) if you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22) and you are divorced from the child's other parent who is now deceased and the marriage lasted less than 10 years.

I can provide spouse information

None

Spouse's Information

Spouse's name (including maiden name)*

When*

Month

Day

Year

Where (Name of City and State)*

How marriage ended*

When*

Month

Day

Year

Where (Name of City and State)*

Marriage performed by:*

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth (or age)*

Month

Day

Year

Date of spouse's death*

Month

Day

Year

Spouse's Social Security Number (If none or unknown, so indicate)*

Other Marriage Information

Enter information about any marriage if you:*

Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before age 22); and
Were married for less than 10 years to the child's mother or father, who is now deceased; and
The marriage ended in divorce If none, write "None."

I can provide Marriage information

None

Marriage Information

Spouse's name (including maiden name)*

When*

Month

Day

Year

Where (Name of City and State)*

How marriage ended*

When*

Month

Day

Year

Where (Name of City and State)*

Marriage performed by:*

Clergyman or public official

Other (Explain in Remarks)

Spouse's date of birth (or age)*

Month

Day

Year

Date of spouse's death*

Month

Day

Year

Spouse's Social Security Number (If none or unknown, so indicate)*

Other Information

If your claim for disability benefits is approved, your children (including adopted children, and stepchildren) or dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on your earnings record.*

FULL NAME OF ALL such children who are now or were in the past 12 months UNMARRIED and:

UNDER AGE 18
AGE 18 TO 19 AND ATTENDING ELEMENTARY OR SECONDARY SCHOOL FULL-TIME
DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)

Full Name*

Did you have wages or self-employment income covered under Social Security in all years from 1978 through last year?*

Yes

List the years from 1978 through last year in which you did not have wages or self-employment income covered under Social Security*

Enter below the names and addresses of all the persons, companies, or Government agencies for whom you have worked this year and last year. IF NONE, WRITE "NONE" BELOW AND GO TO ITEM 16*

NAME AND ADDRESS OF EMPLOYER*

(If you had more than one employer, please list them in order beginning with your last (most recent) employer)

Work Began*

Month

Day

Year

Is work ended ?*

Yes Work Ended

Still Working

Work Ended*

Month

Day

Year

Were you self-employed this year or last year?*

Yes

Check the year (or years) you were self-employed*

This Year

Last Year

In what type of trade/business were you self-employed? (For example, storekeeper, farmer, physician)*

Were your net earnings from the trade or business $400 or more? (Check "Yes" or "No"*

Yes

How much were your total earnings last year? Count both wage and self-employment income. (If none, write "None.")*

Yes (I earned)

None

Amount $*

How much have you earned so far this year? (If none, write "None.")*

Yes (I earned)

None

Amount $*

Are you still unable to work because of your illnesses, injuries, or conditions?*

Yes

Enter the date you became able to work.*

Month

Day

Year

Are your illnesses, injuries, or conditions related to your work in any way?*

Yes

Are you blind or do you have low vision even with glasses or contacts?*

Yes

Have you filed, or do you intend to file, for any other public disability benefits (including workers' compensation, Black Lung benefits and SSI)?*

Yes

The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply)*

Veterans Administration Benefits

Welfare

Supplemental Security Income

Other (If "Other," complete a Workers' Compensation/Public Disability Benefit Questionnaire)

Did you receive any money from an employer(s) on or after the date in item 8 when you became unable to work because of your illnesses, injuries, or conditions? If "Yes", give the amounts and explain in "Remarks".*

Yes

Amount $*

Remarks*

Do you expect to receive any additional money from an employer, such as sick pay, vacation pay, other special pay? If "Yes," please give amounts and explain in "Remarks".*

Yes

Amount $*

Remarks*

Do you, or did you, have a child under age 3 (your own or your spouse's) living with you in one or more calendar years when you had no earnings?*

Yes

Do you have a dependent parent who was receiving at least one- half support from you when you became unable to work because of your disability? If "Yes," enter the parent's name and address and Social Security number, if known, in "Remarks".*

Yes

If you were unable to work before age 22 because of an illness, injury or condition, do you have a parent (including adoptive or stepparent) or grandparent who is receiving social security retirement or disability benefits or who is deceased?*

Yes

Name*

Social Security Number*

Signature of Applicant

Consent*

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives
a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
subject to a fine or imprisonment.

First Name*

Middle Name

Last Name*

Date*

Month

Day

Year

Telephone Number(s) at which you may be contacted during the day. (Include the area code)*

Payment

Service Fee

Price:

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands