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WHAT YOU NEED TO COMPLETE THIS REPORT. Information about all the jobs that you had in the last 5 years before you became unable to work. ANSWER EVERY QUESTION FOR EACH JOB YOU DESCRIBE unless the report indicates otherwise. Provide as much detail as possible.
Forms. 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.
When you mail the SSA-3369-BK to the claimant, include a cover letter asking the claimant to document each job held during the five years before becoming unable to work because of their illnesses, injuries or conditions. You may print and send a partially completed SSA-3369-BK to assist the claimant.
The SSA-3369-BK is used to supplement the SSA-3368-BK to obtain detailed work information when a claimant has performed more than one job in the relevant work period.
The office that makes the disability decision on your case will use the information you provide in this report to decide whether you are disabled. Please complete as much of the report as you can. You may be able to apply online at: www.ssa.gov/apply. WHAT WE MEAN BY "DISABILITY".
If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213. HOW TO COMPLETE THIS FORM. The information that you give us on this form will be used by the office that makes the disability decision on your disability claim.
complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778). HOW TO COMPLETE THIS FORM The information that you give on this form will be used to make a decision on the disabled person's claim.
Obtain the SSA-3368-BK for: Title II disability or blindness claims for Disability Insurance Benefits (DIB), Disabled Widow(er)’s Benefits (DWB), Childhood Disability Benefits ( CDB ), and Disabled Minor Child ( DMC ) claims.
To view this form, go to SSA-3369-BK. To Link to this section - Use this URL: http://policy.ssa.gov/poms.nsf/lnx/0411005153. DI 11005.153 - SSA-3369-BK, Work History Report — Exhibit - 06/20/2012. Batch run: 08/30/2019.
Form SSA-821 | Work Activity Report – Employee. Social Security uses the Work Activity Report form to learn more about the work activity of a disability applicant or beneficiary. If you are applying for disability benefits, the information you provide will help us decide if you can receive benefits.