Social Security DI Application Please enable JavaScript in your browser to complete this form.Name, including maiden name if married * *Address *Email *Comment or MessageDate of Birth and Place of Birth (city and state) *Social Security Number *Telephone number * *Mothers Maiden Name * *FirstLastWhich benefit are you applying for? * *SSDI-disability for those who have sufficient work creditsSSI-disability for lower income individuals and those who do not have sufficient work creditsHow tall are you? *What is your approximate weight? *Is this different from your usual weight? * *Yes, I have lost weightYes, I have gained weightNoWhat hand to you predominantly write with? *LeftRightUnable to writeCan you read in write in English? * *YesNoCan you read and write in Spanish? *YesNoCan you read and write in Khmer? *YesNoCan you read and write in any other language?YesNoHighest grade in school you completed? *Age you completed High School? *Special certifications? *YesNoDo you live in a ________? *ApartmentHouseShelterHomelessAre you married? *YesNoIf yes, Date & Location of Marriage *Who performed ceremony? *Spouse’s Name *Spouse’s DOB *Spouse’s SSN# * Spouse Employed? *YesNoSpouse Receiving SSDI/SSI? *YesNoDo you have any children? *YesNo CHILD 1 Name (put N/A if no child): *Child 1 DOB (put N/A if no child): *Child 1 Address (put N/A if no child): *Child 1 SSN (put N/A if no child):Is this child disabled?YesNoWas this child disabled before age 22? YesNo If yes, please list date disability began: CHILD 2 Name (put N/A if no child): *Child 2 DOB (put N/A if no child): *Child 2 Address (put N/A if no child): *Child 2 SSN (put N/A if no child): *Is this child disabled(put N/A if no child)? *YesNoWas this child disabled before age 22(put N/A if no child)? *YesNoIf yes, please list date disability began (put N/A if no child) *CHILD 3 Name (put N/A if no child): *Child 3 DOB (put N/A if no child): *Child 3 Address (put N/A if no child): *Child 3 SSN (put N/A if no child): *Is this child disabled (put N/A if no child)? *YesNoIf yes, please list date disability began *CHILD 4 Name (put N/A if no child): *Child 4 DOB (put N/A if no child): *Child 4 Address (put N/A if no child): *Child 4 SSN (put N/A if no child): *Is this child disabled (put N/A if no child)? *YesNoWas this child disabled before age 22? *YesNoIf yes, please list date disability began *Have you been married more than once? *YesNoIf yes, please list former spouse(s) name: *Former Spouse DOB: *Date/location of marriage: Date Marriage Ended: How marriage ended: Have you ever served in the military? *YesNoIf yes what branch? *When joined: *Date of Discharge: *Reason for Discharge: *Receiving Veteran Benefits? *YesNoAmount of monthly benefit *Have you ever worked on the railroad? *YesNoHave you ever worked outside the country? *YesNoAdditional Contact Person’s Name *Additional Contact Person’s Phone *Contact Person's relationship to you?Have you previously applied for *SSDISSIShort term disabilityLong term disabilityVeteran BenefitsWorkers CompensationPublic Employee BenefitsWhen did you apply? *Where you approved or denied? *approveddenied If you were approved or denied for any of the above, did you appeal and when? Approximate dates are fine. *Monthly Income $ *Income Source *If you have any other income, please state amount and source. *Do you have a copy of your most recent Social Security statement? *YesNoPlease your most recent employer, including name, address, when you worked there, your job title, how many hours a week you worked and what you were paid. * *If you are still working, have you reduced your hours or responsibilities due to your disability? *YesNoPlease your previous employer, including name, address, when you worked there, your job title, how many hours a week you worked and what you were paid. What employer did you work for prior to your most recent employer? *What do you consider your usual occupation? *Submit
