Form SSA-3368-BK, Disability Report - Adult Completed Form Examples and Samples
Explore a comprehensive example of the SSA-3368-BK form, showcasing how to accurately complete an application for disability benefits. This detailed sample includes sections on personal details, disability description, medical history, and employment background, serving as a practical guide for applicants.
SSA-3368-BK Example – Application for Disability Benefits
How this form was filled:
The applicant's personal information is listed, along with details about the disability, medical treatment, and employment history. This example illustrates how to properly fill out each section to apply for disability benefits.
Information used to fill out the document:
- Applicant’s Name: John Smith
- Date of Birth: 04/01/1980
- Social Security Number: 123-45-6789
- Address: 456 Elm Street, Anytown, USA
- Disability Description: Chronic back pain
- Date Disability Began: 05/01/2024
- Medical Treatment: Dr. Jane Doe, Anytown Medical Clinic, ongoing since 06/2024
- Medications: Ibuprofen 800 mg, Physical Therapy
- Recent Employment: XYZ Corp, Clerk, 01/2022 - 01/2024
- Previous Employment: ABC Ltd, Assistant, 06/2018 - 12/2021
What this filled form sample shows:
- Complete applicant identification with personal details
- Detailed description of disability and start date
- Comprehensive list of medical treatments and medications
- Full outline of recent and previous employment history
Form specifications and details:
| Use Case: | Application for disability benefits due to chronic condition |
| Year: | 2025 |
| Eligibility: | Applicants with a significant disability impacting work ability |
