Get the free form approved omb 0960 0578 2009 - ip70-171-228-108 tc ph cox

FORM APPROVED OMB NO. 0960-0578 SOCIAL SECURITY ADMINISTRATION WORK HISTORY REPORT SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON A. Name First Middle Initial Last JENNIFER DELMAR LEWIS XXX-XX-7002 C. DAYTIME TELEPHONE NUMBER If you have no number where you can be reached give us a daytime number where we can leave a message for you. u Your Number u Message Number u None Area Code Number List all of the jobs that you had in the 15 years before you became unable to work because of your...

How to fill out form approved omb 0960

How to fill out SSA-3369-BK

1. Obtain Form SSA-3369-BK from the Social Security Administration's website or local office.
2. Read the instructions carefully to understand the purpose of the form.
3. Fill out the individual's personal information at the beginning of the form, including name, address, and social security number.
4. Provide details about the individual's medical condition in the relevant sections.
5. Include names and contact information for all healthcare providers who have treated the individual.
6. Describe the individual's daily activities and how their condition affects their ability to work.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form before submitting it to the appropriate Social Security office.

Who needs SSA-3369-BK?

1. Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) who are required to provide information about their mental or physical impairments.

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What is SSA-3369-BK?

SSA-3369-BK is a form used by the Social Security Administration (SSA) to collect information about an individual's work history and medical conditions related to their disability claim.

Who is required to file SSA-3369-BK?

Individuals who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) and need to provide information on their work history and medical conditions are required to file SSA-3369-BK.

How to fill out SSA-3369-BK?

To fill out SSA-3369-BK, individuals should provide accurate details about their past jobs, medical conditions, treatment history, and any relevant work limitations. It's important to follow the instructions carefully and complete all sections.

What is the purpose of SSA-3369-BK?

The purpose of SSA-3369-BK is to gather comprehensive information about an applicant's work experience and health issues in order to assess their eligibility for disability benefits.

What information must be reported on SSA-3369-BK?

SSA-3369-BK requires reporting information such as job titles, job duties, dates of employment, medical diagnoses, treatment history, and how medical conditions affect the ability to work.