[Code of Federal Regulations]
[Title 20, Volume 2]
[Revised as of April 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR422.505]

[Page 1090-1091]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
               CHAPTER III--SOCIAL SECURITY ADMINISTRATION
 
PART 422_ORGANIZATION AND PROCEDURES--Table of Contents
 
                Subpart F_Applications and Related Forms
 
Sec. 422.505  What types of applications and related forms are used to 
apply for retirement, survivors, and disability insurance benefits?

    (a) Applications. Prescribed applications include our traditional 
pre-printed forms, and applications our employees complete on computer 
screens based on information you give us. We then print a copy on paper, 
have you sign it and process the signed application electronically. You 
may also use SSA's Internet website to submit an SSA-approved 
application to us. You can complete an Internet application on a 
computer (or other suitable device, such as an electronic kiosk) and 
electronically transmit the form to us using an SSA-approved electronic 
signature. If, however, we do not have an approved electronic signature 
established when you file your Internet application, you must print and 
sign the completed application and deliver the form to us.
    (b) Related forms. The following are some related forms:

SSA-3--Marriage Certification. (For use in connection with Application 
for Wife's or Husband's Insurance Benefits, (Form SSA-2))

[[Page 1091]]

SSA-11--Request to be Selected as Payee. (For use when an individual 
proposing to be substituted for the current payee files an application 
to receive payment of benefits on behalf of disabled child, or a child 
under 18, or an incapable or incompetent beneficiary or for himself/
herself if he/she has a payee.)
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-25--Certificate of Election for Reduced Spouse's Benefits. (For use 
by a wife or husband age 62 to full retirement age who has an entitled 
child in his or her care and elects to receive reduced benefits for 
months during which he or she will not have a child in his or her care.)
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). (For 
use in collecting evidence of support.)
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-783--Statement Regarding Contributions. (This form may be used as 
evidence of total contributions for a child.)
SSA-787--Physician's/Medical Officer's Statement of Patient's Capability 
to Manage Benefits. (This form may be used to request evidence of 
capability from various medical sources.)
SSA-824--Report on Individual with Mental Impairment. (For use in 
obtaining medical evidence from medical sources when the claimant has 
been treated for a mental impairment.)
SSA-827--Authorization for Source to Release Information to the Social 
Security Administration. (To be completed by a disability claimant to 
authorize release of medical or other information.)
SSA-1002--Statement of Agricultural Employer (Years Prior to 1988). (For 
use by employer to provide evidence of annual wage payments for 
agricultural work.)
SSA-1372--Student's Statement Regarding School Attendance. (For use in 
connection with request for payment of child's insurance benefits for a 
child who is age 18 through 19 and a full-time student.
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-1724--Claim for Amount Due in the Case of a Deceased Beneficiary. 
(For use in requesting amounts payable under title II to a deceased 
beneficiary.)
SSA-3368--Disability Report--Adult. (For use in recording information 
about the claimant's condition, source of medical evidence and other 
information needed to process the claim to a determination or decision.)
SSA-3369--Disability Report--Work History. (For use in recording work 
history information.)
SSA-3826-F4--Medical Report--General. (For use in helping disability 
claimants in obtaining medical records from their doctors or other 
medical sources.)
SSA-3827--Medical Report--(Individual with Childhood Impairment). (For 
use in requesting information to determine if an individual's impairment 
meets the requirements for payment of childhood disability benefits.)
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 Questionnaire. (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.)
SSA-7163--Questionnaire about Employment or Self-Employment Outside the 
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.)

[69 FR 499, Jan. 6, 2004]