Form SSA-16, Application for Disability Benefits Completed Form Examples and Samples
Explore a filled example of Form SSA-16, Application for Disability Benefits, showcasing critical details like citizenship status, disability specifics, employment history, and contact information. Learn how to properly complete this essential form.
SSA-16 Example – Application for Disability Benefits
How this form was filled:
In this example, the applicant, Jane Doe, a U.S. citizen born on January 5, 1975, applies for disability benefits due to arthritis. Her application highlights critical fields like citizenship status, disability details, employment history, and contact information.
Information used to fill out the document:
- Applicant’s Name: Jane Doe
- Social Security Number: 123-45-6789
- Date of Birth: 01/05/1975
- Citizenship Status: U.S. Citizen
- Medical Condition: Arthritis
- Employment History: Worked at Springfield Manufacturing from 2010 to 2022
- Contact Address: 456 Elm Street, Springfield, USA
- Phone Number: 555-123-4567
- Date of Application: 09/15/2025
What this filled form sample shows:
- Accurate listing of personal information including full name and date of birth
- Clear description of medical condition leading to disability
- Detailed employment history for the past 15 years
- Complete citizenship information indicating U.S. citizenship
- Properly formatted contact information with phone number and address
Form specifications and details:
| Use Case: | U.S. citizen applying for disability benefits due to a chronic medical condition |
