[Title 20 CFR 422.505]
[Code of Federal Regulations (annual edition) - April 1, 1996 Edition]
[Title 20 - EMPLOYEES' BENEFITS]
[Chapter III - SOCIAL SECURITY ADMINISTRATION]
[Part 422 - ORGANIZATION AND PROCEDURES]
[Subpart F - Applications and Related Forms]
[Sec. 422.505 - Applications and related forms for retirement, survivors, and disability insurance programs.]
[From the U.S. Government Publishing Office]




  20
  EMPLOYEES' BENEFITS
  2
  1996-04-01
  1996-04-01
  false
  
  422.505
  Sec. 422.505
  
    EMPLOYEES' BENEFITS
    SOCIAL SECURITY ADMINISTRATION
    ORGANIZATION AND PROCEDURES
    Applications and Related Forms
  


Sec. 422.505   Applications and related forms for retirement, survivors, and disability insurance programs.

    (a) Applications. To facilitate claims taking, the Social Security 
Administration (SSA) has designed applications to be used by the public 
when claiming benefits under title II of the Social Security Act. 
Prescribed applications include our traditional printed forms and our 
computer printouts. The printouts are similar in content to the 
traditional application, forms, but are produced only after an SSA 
employee has keyed into a computer terminal the answers the applicant 
has given to the relevant questions. The information on the applications 
includes such items as date of birth, family relationship, work history, 
etc. The printout may omit questions that the computer recognizes as 
irrelevant as a result of the answers to other questions. Phrasing may 
differ from that on the traditional printed forms.
    (b) Related forms. The following are some related forms:

SSA-3--Husband's Certification. (For use in connection with Application 
for Wife's Insurance Benefits, Form SSA-2.)
SSA-8a--Supplement to Form SSA-8 (Application for Lump-Sum Death 
Payment). (For use with a funeral home's application for lump-sum death 
payment, Form SSA-8).
SSA-11--Application to be Selected as Payee. (For use when the 
individual proposing to be substituted for current payee files 
application to receive payment of benefits on behalf of himself, a 
disabled child or child under age 22, a student beneficiary, or an 
incompetent beneficiary.)
SSA-15--Wife's Certification. (For use in connection with Application 
for Husband's Insurance Benefits, Form SSA-14.)
SSA-17--Statement Regarding Disability (By Widow, Widower, Surviving 
Divorced Wife, or Child). (For use in connection with a request for 
payment of benefits due to disability by a widow, widower, surviving 
divorced wife, or a child who is age 18 or over and is under a 
disability which began before age 22.)
SSA-21--Supplement to Claim of Person Outside of the United States. (To 
be completed by or on behalf of a person who is, was, or will be outside 
the United States.)
SSA-22--Supplement to Claim on Behalf of Child Outside the United 
States. (To be completed for a child who is, was, or will be outside the 
United States.)
SSA-25--Certificate of Election for Reduced Wife's Benefits. (For use by 
a wife age 62 through 64 who has an entitled child in her care and 
elects to receive reduced benefits for months during which she will not 
have a child in her care.)
SSA-401--Medical History and Disability Report.
SSA-401A--Report of Disability Interview--Widow (Divorced Wife) and 
Widower.
SSA-401CH--Report of Childhood Disability Interview. (Forms SSA-401, 
SSA-401A, and SSA-401CH are for use in documenting a claimant's medical 
history together with the course and effects of the claimant's 
vocational history.)
SSA-717--Statement of Person Requesting Payment on Behalf of Estate.
SSA-718--Consent by Relative for Payment to Individual on Behalf of 
Estate.
SSA-719--Statement of Burial Expenses by Funeral Director. (To be 
completed by the funeral director in connection with an individual's 
(other than a widow or widower who was living in the same household with 
the insured individual at the time of his death) application authorizing 
direct payment of the lump-sum death payment to the funeral director.) 
(See Form SSA-8 under Sec. 422.505(a).)
SSA-721--Statement of Death by Funeral Director. (This form may be used 
as evidence of death (see Sec. 404.704 of this chapter).)
SSA-760--Certificate of Support (Parent's, Husband's, or Widower's).
SSA-766--Statement of Self-Employment Income. (For use by a claimant to 
establish insured status based on self-employment income in the current 
year.)
SSA-780--Certificate of Applicant for Benefits on Behalf of Another. 
(This form accompanies an individual's or institution's request to be 
selected payee for a beneficiary and is used to determine the 
requester's interest in the welfare of the beneficiary.)
SSA-786--Physician's Statement. (For use in requesting medical evidence 
of a beneficiary's capacity to manage benefits.)
SSA-787--Medical Officer's Statement. (For use in requesting medical 
evidence of a beneficiary's capacity to manage benefits from an 
institution.)
SSA-823--Request for Medical Evidence to Hospital or Institution. (For 
use in requesting information regarding hospitalization or treatment of 
a disability claimant.)
SSA-824--Report on Individual With Mental Impairment. (For use in 
requesting information regarding a disability claimant's mental 
impairment.)
SSA-826--Medical Report--General. (For use in obtaining medical 
information concerning a disability claimant.)
SSA-826.1--Medical Report--Pulmonary Tuberculosis. (For use in 
requesting medical evidence from a hospital in which a

[[Page 946]]

disability claimant is confined for the treatment of tuberculosis.)
SSA-827--Applicant's Request for Medical Information. (To be completed 
by a disability claimant to authorize release of medical information.)
SSA-1001--Statement of Employer. (For use by an employer to provide 
evidence of quarterly wage payments.)
SSA-1002--Statement of Agricultural Employer. (For use by an employer to 
provide evidence of annual wage payments for agricultural work.)
SSA-1372--Student's Statement Regarding School Attendance. (For use in 
connection with a request for payment of child's insurance benefits for 
a child who is age 18 through 21 and a full-time student.)
SSA-1372A--Certification by School Official of Student's Full-time 
Attendance. (For use with requests for child's insurance benefits for 
students age 18 through 21.)
SSA-1372A(F)--Statement to U.S. Social Security Administration by School 
Outside the United States About Student's Attendance. (For use in 
connection with a request for payment of child's insurance benefits for 
a child who is age 18 through 21 and a full-time student outside the 
United States.)
SSA-1388--Report of Student Beneficiary at End of School Year. (For use 
in confirming continuing eligibility to benefits or indicating the need 
for suspension or termination action.)
SSA-1442--Statement by Divorced Woman Regarding Contributions and 
Support From Her Former Husband.
SSA-1724--Claim for Amounts Due in the Case of a Deceased Beneficiary. 
(For use in requesting amounts payable under title II to a deceased 
beneficiary.)
SSA-4111--Certificate of Election for Reduced Widow(er)'s Benefits. (For 
use by applicants for certain reduced widow's or widower's benefits.)
SSA-7156--Farm Self-Employment Questionaire. (For use in connection with 
claims for benefits based on farm income to determine whether the income 
is covered under the Social Security Act.)
SSA-7160--Employment Relationship Questionnaire. (For use by an 
individual and the alleged employer to determine the individual's 
employment status.)
DDS-7163--Questionnaire About Employment or Self-Employment Outside 
United States. (To be completed by or on behalf of a beneficiary who is, 
was, or will be employed or self-employed outside the United States.)
SSA-7203--Sick Pay and Plan or System Questionnaire. (To be completed by 
an employer for the purpose of determining the nature of special 
payments to an employee.)

[38 FR 11450, May 8, 1973, as amended at 51 FR 41952, Nov. 20, 1986; 55 
FR 25826, June 25, 1990]