Notices to Beneficiaries who Have Third Parties Applying for them Via ISBA

{Conditional Notice #1} 

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information
______________(1b)_______
______________(1c)_______
___(1d)_______(1e)__(1f)__
Date: _________(2)_______
Claim Number: __(11)____
_________(3a)_____________
_________(3b)_____________
_________(3c)_____________
__(3d)____(3e)_______(3f)__

Telephone:

____(1h)______

An Internet application for Social Security benefits was started for you by
_____(4)_______ ____(5)_______ on _____(6)______. If you want this person to
continue on your behalf, you do not need to take any action at this time.
What Happens Next
Once _____________(4)___________ finishes entering all required information, we
will mail you a printed copy of the completed application to review and sign. After
you review the application and make sure it is correct, you must sign and return it
to the office address shown above. We will not take any action until we receive
your signed application.
Once we receive your application, we will decide if you can get benefits. The
sooner we receive it, the sooner we can decide.
We may use ____(6)____ as the official date of this application. In order to use
____(6)____, we must receive the signed application by ____(7)____. You may lose
Social Security benefits if we do not receive the signed application by
____(7)____.
Supplemental Security Income or SSI is a federal program that provides monthly
payments to people who have limited income and assets and who are age 65 or
older, or blind or have a disability. For more information about the SSI program,
please read the pamphlet, Supplemental Security Income.
If you intend to apply for SSI, you need to file your application with us by
_____(12)______ or you may lose SSI benefits. Call us at 1­800­772­1213 (TTY
1­800­325­0778) to arrange an appointment to file for SSI. You cannot apply for
SSI over the Internet.
SSA­L1 (9/2008)

Claim #: 999­99­9999 

Page 2 of 2

Additional Information
If you want to get in touch with the person who started your Internet application,
the address is: ____(8)_______. The telephone number is _____(9)______.
If You Have Any Questions
If you have any questions, call, write, or visit any Social Security office and have
this letter with you. The telephone number and mailing address of your local
office are shown at the top of this letter.
You can also reach us at 1­800­772­1213 (TTY 1­800­325­0778). We can answer
most questions over the phone. The office location is: (C1)
______________(10b)_______
______________(10c)_______
___(10d)____(10e)___(10f)__
(C1)

{Insert choice of UTI SSAS­30 – SSAS­39 (Signature Authority: Regional
Commissioner’s printed name and Region) based on applicant’s zip code.}

SSA­L1 (9/2008)

Fill‐ins 
Fill‐in 1b‐1h 
Fill 1b‐1h with the following items for the claimant’s servicing field office as derived from the 
claimant’s zip code. 
1b – mailing address 
1c – mailing address, line 2 
1d – City 
1e – State 
1f – Zip Code 
1h ‐ phone number 
Fill‐in 2 
Date of notice: Calculate and display the batch run date plus 7 business days. 
(Format: Month DD, YYYY) 
Fill‐in 3a – 3f 
Applicant name and mailing address 
3a – name of applicant (Format: First MI/Middle Last) 
3b – mailing address 
3c – mailing address, line 2 
3d – City 
3e – State 
3f – Zip Code 
Fill‐in 4 
Name of third party who started the Internet application. 
Format: First MI/Middle Last, Suffix (use a “Special K” UTI) 
Fill‐in 5 
If organization exists display a variable length fill‐in for name of the organization with which the 
third party is associated. 
[Display “of ___________” if organization exists.] 
Fill‐in 6 
Month, day and year the third party started the Internet application. 
(Format: Month DD, YYYY) 
Fill‐in 7 
Calculate and display the closeout date (equal to 6 calendar months plus 7 calendar days 
after the start date of the ISBA application. 
(Format: Month DD, YYYY). The 6‐month interval is equal to 6 calendar months and not 
180 days. (E.g.: Six months from Jan 15th will be July 15 th . Seven additional calendar 
days are then added, and if that day falls on a non‐business day (weekend or holiday), 
then add days until the next business day is been reached.

Fill‐in 8 
Complete address of the third party (street address, street address line 2, city/state/zip code) 
in‐line as single comma separated string. 
Fill‐in 9 
Telephone number of the third party, including area code and extension if exists. 
Fill‐in 10b ‐ 10f 
Use the physical location of the claimant’s servicing field office as derived from the claimant’s 
zip code. 
10b – mailing address 
10c – mailing address, line 2 
10d – City 
10e – State 
10f – Zip Code 
Fill‐in 11 
Complete SSN of the applicant 
Fill‐in 12 
Calculate and display the SSI closeout date. The closeout period starting date begins seven 
calendar days after generation of the Application Number (start date of the ISBA) and ends 60 
calendar days after that date. (Format: Month DD, YYYY). If the ending date falls on a non‐ 
business day (weekend or holiday), then add days until the next business day has been reached. 

Conditional Text Blocks 
C1 – Print these when the SSA Office’s physical address is different than the mailing address

{Comprehensive Notice #2}

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information
______________(1b)_______
______________(1c)_______
___(1d)_______(1e)__(1f)__
Date: _________(2)_______
Claim Number: __(13)____
_________(4a)_____________
_________(4b)_____________
_________(4c)_____________
__(4d)____(4e)_______(4f)__

Telephone: ____(1h)______
Confirmation Number: __(3)___
An Internet application for Social Security benefits was completed for you by
______ (5) ______ ____ (6) _____ on _____(8)______. We stored the information in
our records and have included the application for your review and signature.
If you do not want these benefits, you do not need to contact us. We will not take
any action unless we receive your signed application.
What You Need to Do
·

Review all the entries on the application and confirm that the information is
correct.

·

Correct any information that is wrong and write your initials next to it.

·

Sign and date the application in the space shown as, “Your Signature.”
NOTE: It is important that you sign the application, not the person who
filled it in for you or anyone else.

·

Gather the documents shown on the enclosed List of Acceptable Evidence.
We will return all documents and photocopies to you unless you tell
us you don’t want them. (C1)

·

If you decide to continue applying for disability, complete all forms SSA­827
(Authorization to Disclose Information to the Social Security Administration)
as shown below: 
1.  Read the entire form SSA­827, front and back. 
2.  Write your name and Social Security Number in the upper right corner of
each form. 
3.  Sign each form in the space shown as “INDIVIDUAL authorizing
disclosure.” 
4.  Enter your address and daytime phone number in the spaces shown for
them. 
5.  Date each form in the space shown as “Date Signed.”
SSA­L2 (9/2008) 

Claim #: 999­99­9999 

Page 2 of 18 

6.  Do not fill in the large empty box in the middle of the form, put a check in
the empty block under “PURPOSE,” or complete any other sections of the
form. 
7.  Have a witness sign and provide his or her address or phone number in
the space shown on each form. If you sign with an “X,” have a second
witness sign and provide his or her address. (C2)
·

Mail or bring the signed application, any proofs requested on the List of
Acceptable Evidence (C1) and all the Medical Release forms (SSA­827).
(C2) If you mail them, please follow the mailing instructions on the final
page of this notice and add your return address and correct postage to the
envelope provided. If the office location is different than the mailing address,
it is listed in “If You Have Any Questions.” (C3)

·

If you do not want to apply for disability, you do not need to return the SSA­
827s with your retirement application. (C2)

What Happens Next
Once we receive your signed application, we will decide if you can get benefits.
The sooner we receive it, the sooner we can decide.
We may use ____(7)____ as the official date of this application. In order to use
____(7)____, we must receive the signed application by ____(9)____. You may lose
Social Security benefits if we do not receive the signed application by
____(9)____.
Supplemental Security Income or SSI is a federal program that provides monthly
payments to people who have limited income and assets and who are age 65 or
older, or blind or have a disability. For more information about the SSI program,
please read the pamphlet, Supplemental Security Income.
______ (5) ______ indicated that you intend to apply for SSI. You need to file your
application with us by _____(14)______ or you may lose SSI benefits. Call us at
1­800­772­1213 (TTY 1­800­325­0778) to arrange an appointment to file for SSI.
You cannot apply for SSI over the Internet. (C4)
Confirmation Number
You can check the status of your application on the Internet. Please wait at least
5 business days from the date you mail or bring your signed application to us
before you check your application status. To check the status, go to Social
Security Online and select “What You Can Do Online.” It can be found at
www.socialsecurity.gov/onlineservices. Select “Check the status of your
application” and enter the Confirmation Number shown at the top of this notice.
Please guard this number carefully. It's the key to your application information.
Social Security employees will never ask for your Confirmation Number.
Disability claims take longer to process than other types of Social Security claims.
We have to get enough medical evidence to show that you are disabled. It may
take 90 – 120 days before “Check the status of your application” will show if
you can get disability benefits. (C2) 
SSA­L2 (9/2008)

Claim #: 999­99­9999 

Page 3 of 18 

Additional Information
If you want to get in touch with the person who completed your application, the
address is: ______ (10) __________. The telephone number is ____ (11) _________.
If You Have Any Questions
If you have any questions, call, write, or visit any Social Security office and have
this letter with you. The telephone number and mailing address of the office
processing your claim are shown at the top of this letter.
You can also reach us at 1­800­772­1213 (TTY 1­800­325­0778). We can answer
most questions over the phone. The office location is: (C3)
______________(12b)_______
______________(12c)_______
___(12d)____(12e)___(12f)__
(C3)
{Insert choice of UTI SSAS­30 – SSAS­39 (Signature Authority: Regional
Commissioner’s printed name and Region) based on applicant’s zip code.}

Enclosures –
Return Envelope
Application Summary
List of Acceptable Evidence Documents (C1)
Medical Releases (SSA­827) (C2) 

SSA­L2 (9/2008)

Claim #: 999­99­9999 

Page 4 of 18 

List of Acceptable Evidence Documents (C1)
You need to send us the documents shown below. Send all documents you have
with your signed application. We will help you get the other documents. You
should not delay sending your application if you don’t have all the
documents. You may lose benefits if you delay.
NOTE: Include your Social Security number when you mail documents to us. We
need this to match the documents to your application. Please write your Social
Security number on a separate sheet of paper and include it in the envelope with
your documents. Do not write anything on your original documents. You may
bring the documents to any Social Security office if you don’t want to mail them.
They will be examined and returned to you.
CAUTION: Don’t mail foreign birth records or any Department of Homeland
Security (DHS) documents to us – especially those you are required to keep with
you at all times. These documents are extremely difficult, time­consuming, and
expensive to replace if lost. Some cannot be replaced. Instead, bring them to any
Social Security office where they will be examined and returned to you.
Proof of Age (C6)
You must submit a birth certificate or religious record of birth made before you
were age 5 if one was established. This is our preferred proof of age.
You need to provide at least two other documents to prove your age if a public or
religious record was not made prior to age 5. Examples of other documents include
a delayed birth certificate, school records, a State census record, vaccination
record, insurance policy, hospital admission record, etc. Please provide us with two
of the oldest of these documents.
We must see the original document(s). We cannot accept photocopies unless
they are certified by the office that issued the original. We will return any
document you show us.
Proof of Citizenship or Naturalization (C7)
We can accept most documents that show that you were born in the United States.
We need to see a document such as a U.S. consular report of birth, a U.S.
passport, a Certificate of Naturalization, or a Certificate of Citizenship if you are a
U.S. citizen born outside the U.S.
If you are not a U.S. citizen we need to see your INS Form 1­551 (Green Card) to
verify your 9­digit Alien Registration Number (A­Number). We need to see your
INS Form I­94 to verify your Admission Number if you have an 11­digit Admission
Number, even if you have an A­Number.
We must see the original documents, but we cannot accept them if they have
expired. We cannot accept photocopies.
Proof of U.S. Military Service Before 1968 (C8)
Your benefit amount may increase if you have any period of active duty in the U.S.
military prior to 1968. We need proof of your active duty service to determine this.
Military service credits for active duty are automatically posted after 1967. Proof

Claim #: 999­99­9999 

Page 5 of 18 

of U.S. military service includes your military service papers (e.g., Form DD­214­
Certification of Release or Discharge from Active Duty). We need to see all DD­
214s with beginning and ending dates of active duty prior to 1968. We can accept
uncertified photocopies of your military service.
Proof of Wages from Your Employer (C9)
We need to see Form W­2 for wages you received last year. We can accept pay
stubs or statements for the current year as long as Social Security earnings (also
known as FICA or OASDI earnings) are displayed separately. We can accept
uncertified photocopies of your W­2 forms.
Proof of Self­Employment Income (C10)
We need to see a copy of Schedule C and SE from your tax return for last year. We
can accept uncertified photocopies of your self­employment tax returns.
Medical Evidence (C11)
We will ask for your medical documents if you have received treatment for your
alleged disability. This includes copies or photocopies of medical records, doctors’
reports, and recent test results. Your treatment records are used along with other
information to see if you meet our definition of disability.
We need information about your medical treatment for any illnesses, injuries, or
conditions that limit your ability to work. We will not need to request copies of
medical documents from your doctors, hospitals, clinics, or other medical sources if
you already have them. We can process your application faster with this
information. Do not delay filing your application if you do not have these
documents. We will ask the medical sources you list to send them to us. We may
ask you to go to a special examination at our expense if you have not received
treatment, or we do not obtain enough documents about your condition(s).
We also ask for information such as:
· What are your illnesses, injuries, or conditions?
· When did they begin?
· How do they limit your activities?
· What did medical test show?
· What treatment did you receive?
In addition, we ask for information about your ability to do work­related activities,
such as walking, sitting, lifting, carrying, and understanding and remembering
instructions.
We do not ask your doctors to decide if you are disabled.
We can accept uncertified photocopies of your medical documents.
Proof of Workers’ Compensation and/or Similar Benefits (C12)
You indicated that you received or are receiving a temporary or permanent
workers’ compensation­type benefit. We need to see award letters, pay stubs,
settlement agreements or other proof you may have.
We will need documents that show:
· The date of your injury or illness;
· The amount and effective date of your current payment and all increases or
decreases within the last 17 months or, if later, since payments began;

Claim #: 999­99­9999 
·
·
·
·
·

Page 6 of 18

The type of payment if you receive workers’ compensation (i.e., temporary
partial, temporary total, permanent partial, permanent total, a lump sum, or
an annuity);
The frequency of your payments (e.g., weekly, bi­weekly, monthly, bi­
monthly, etc.) or the period covered by a lump sum;
The last day you were entitled to a payment and the last payment amount (if
different from your regular payment amount) if benefits have already ended;
The name, address, and phone number of your employer;
The name, address, and phone number of the insurance carrier if they make
the payments instead of your employer.

We can accept uncertified photocopies of your workers’ compensation and/or
similar benefit information.

Claim #: 999­99­9999 

Page 7 of 18 

Internet Social Security Benefit Application Summary
Instructions
This form summarizes all the information provided by the person who started an
Internet application for Social Security benefits on your behalf.
1.
2.
3.
4.

Review all the entries and confirm that the information is correct.
Write your initials next to any corrections that you make.
Sign and date the application in the space shown as, “Your Signature.”
NOTE: It is important that you sign the application, not the person who
filled it in for you or anyone else.
5. Mail or bring the signed application to the office address shown on the notice
mailed with this summary. If you mail it, add your return address and the
correct postage to the envelope provided.
6. If the office location is different than the mailing address, it is listed under
“If You Have Any Questions” at the end of the notice. (C3) 
I apply for all insurance benefits for which I am eligible under Title II (Federal Old­Age, Survivors, and 
Disability Insurance) and Part A of Title XVIII (Health Insurance for the Aged and Disabled) of the 
Social Security Act, as presently amended. 

Applicant Identification 
Applicant name: Erika Davies 
Social Security Number: XXX­XX­9999 
Gender: Female 
Date of Birth: October 18, 1950 
Preparer’s Information 
Preparer’s name: Doug Bender 
Preparer’s organization: Bender & Bender, LLC 
Preparer’s relationship to applicant: Attorney 
Preparer’s address: 123 Old Court Rd., Baltimore, MD 21208 
Preparer’s phone number: (410) 224­9444 

Contact Information 
Mailing Address 
Mailing Address: 3601 Clark’s Lane, Baltimore, MD 21215 
Reside at this address: No 
Residence Address: 2415 St. Paul Street, Baltimore, MD 21218 

Phone and email 
Daytime telephone number: 443­765­4008 
Type of phone: Other 
Best time to call: 2 
Email address: erika.seth@gmail.com 
Preferred language for speaking: English 
Preferred language for reading: English 

Birth and Citizenship Information 
Born in the United States or a U.S. territory or commonwealth: Yes 
City of birth: Baltimore

Claim #: 999­99­9999 
State of birth: MD 
U.S. citizen: Yes 
Type of citizenship: U.S. Citizen born inside the U.S. 

Confirmation Number 
The confirmation number is: 12345678 

Other Social Security Numbers 
Any other Social Security Numbers used: Yes 
Other SSN 1: 444­99­4444 
Other SSN 2: 
Other SSN 3: 
Other SSN 4: 
Other SSN 5: 

Other Names 
Any other names used: Yes 
Other name 1: Erika Seth 
Other name 2: 
Other name 3: 
Other name 4: 
Other name 5: 

Marriage Information 
Currently married: Yes 
Spouse's Name: Edward Davies 
Spouse's Social Security Number: 909­99­9999 
Spouse's age: 62 
Marriage Date: April 19, 1988 
Marriage Type: Married by Clergy or Public Official 
Married in U.S. or a U.S. territory or commonwealth: Yes 
City, town or county: 
U.S. state, territory or commonwealth: 

Prior Marriages 
First prior spouse’s name: Eric Smith 
First prior spouse’s Social Security Number: UNKNOWN 
First prior spouse’s date of birth: December 15, 1952 
First prior marriage began on: April 28, 1971 
First prior marriage type: Clergy or Public Official 
First prior marriage began in: Bath, England 
First prior marriage ended on: October 4, 1974 
First prior marriage ended in: Bath England 
First prior marriage ended because of: Death 
Second prior spouse’s name: John Doe 
Second prior spouse’s Social Security Number: UNKNOWN 
Second prior spouse’s date of birth: December 15, 1952 
Second prior marriage began on: April 28, 1971 
Second prior marriage type: Clergy or Public Official 
Second prior marriage began in: Bath, England 
Second prior marriage ended on: October 4, 1974 
Second prior marriage ended in: Bath England 
Second prior marriage ended because of: Death

Page 8 of 18 

Claim #: 999­99­9999 
Third prior spouse’s name: Peter Piper 
Third prior spouse’s Social Security Number: UNKNOWN 
Third prior spouse’s date of birth: December 15, 1952 
Third prior marriage began on: April 28, 1971 
Third prior marriage type: Clergy or Public Official 
Third prior marriage began in: Bath, England 
Third prior marriage ended on: October 4, 1974 
Third prior marriage ended in: Bath England 
Third prior marriage ended because of: Death 
Fourth prior spouse’s name: Grant Tomb 
Fourth prior spouse’s Social Security Number: UNKNOWN 
Fourth prior spouse’s date of birth: December 15, 1952 
Fourth prior marriage began on: April 28, 1971 
Fourth prior marriage type: Clergy or Public Official 
Fourth prior marriage began in: Bath, England 
Fourth prior marriage ended on: October 4, 1974 
Fourth prior marriage ended in: Bath England 
Fourth prior marriage ended because of: Death 
I have NO additional prior marriages. 

Children 
Child 1: Ethan Davies 
Child 2: Ephraim Davies 
Child 3: 
Child 4: 
Child 5: 
Child 6: 
Child 7: 
Child 8: 
Child 9: 
Child 10: 
I have NO additional children. 

Military Details 
Military Service prior to 1968: Yes 
Receiving or eligible to receive military or civilian Federal agency benefit: Yes 
Type of benefit: Military 
First Military Period Type of Duty: Reserve 
First Military Period Branch of Service: Army 
First Military Period Start Date: 02/02/1934 
First Military Period End Date: 02/02/1936 
Second Military Period Type of Duty: Reserve 
Second Military Period Branch of Service: Army 
Second Military Period Start Date: 02/02/1934 
Second Military Period End Date: 02/02/1936 
Third Military Period Type of Duty: Reserve 
Third Military Period Branch of Service: Army 
Third Military Period Start Date: 02/02/1934 
Third Military Period End Date: 02/02/1936

Page 9 of 18 

Claim #: 999­99­9999 
Fourth Military Period Type of Duty: Reserve 
Fourth Military Period Branch of Service: Army 
Fourth Military Period Start Date: 02/02/1934 
Fourth Military Period End Date: 02/02/1936 
Fifth Military Period Type of Duty: Reserve 
Fifth Military Period Branch of Service: Army 
Fifth Military Period Start Date: 02/02/1934 
Fifth Military Period End Date: 02/02/1936 
Sixth Military Period Type of Duty: Reserve 
Sixth Military Period Branch of Service: Army 
Sixth Military Period Start Date: 02/02/1934 
Sixth Military Period End Date: 02/02/1936 
Seventh Military Period Type of Duty: Reserve 
Seventh Military Period Branch of Service: Army 
Seventh Military Period Start Date: 02/02/1934 
Seventh Military Period End Date: 02/02/1936 
Eighth Military Period Type of Duty: Reserve 
Eighth Military Period Branch of Service: Army 
Eighth Military Period Start Date: 02/02/1934 
Eighth Military Period End Date: 02/02/1936 
Ninth Military Period Type of Duty: Reserve 
Ninth Military Period Branch of Service: Army 
Ninth Military Period Start Date: 02/02/1934 
Ninth Military Period End Date: 02/02/1936 
Tenth Military Period Type of Duty: Reserve 
Tenth Military Period Branch of Service: Army 
Tenth Military Period Start Date: 02/02/1934 
Tenth Military Period End Date: 02/02/1936 
I have NO additional Periods of Military Duty. 

Employer Details 
Worked for an employer in 2007: YES 
Worked or will work for an employer in 2008 
Will work for an employer in 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES

Page 10 of 18 

Claim #: 999­99­9999 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Employer’s name: Southwest Airlines 
Employer’s address: 1 Plain Dr., Chicago, IL 00747 
Date employment began: September 1987 
Date employment end: March 2007 
Another employer in 2007, 2008, or 2009: YES 
Self­employment Details 
Self­employed in 2007: YES 
Type of business:  Law firm 
Self­Employment net income greater than $400: YES 
Self­employed in 2008: YES 
Type of business:  Home medical practice 
Self­Employment net income greater than $400: YES 
Self­employed in 2009: YES 
Type of business:  Car wash 
Self­Employment net income greater than $400: YES 
Supplemental Information 
Worked outside the US: YES 
Eligible for benefits under a foreign social security system: YES 
Country: Pakistan 
Filed or intend to file under that country’s social security system: YES 
Spouse worked outside the US: YES 
Spouse eligible for benefits under a foreign social security system: YES 
Spouse filed or intends to file under that country’s social security system: YES

Page 11 of 18 

Claim #: 999­99­9999 

Page 12 of 18 

Agree with the earning history as shown on Social Security statement: YES 
Corporate Officer of employer: YES 
Related to a Corporate Officer of employer: YES 
Receiving earnings from a Family Corporate or other closely held corporation: YES 
Permission granted to contact employer(s) if necessary: YES 
Total Earnings 
Total of all wages and tips in 2007: $12000 
Earned wages, tips, and net earnings from self­employment over $1080 a month or performed 
substantial services in self­employment in all months of 2007: NO 
Months did not earn over $1080: January, March and June 
Total of all wages and tips in 2008: $15000 
Earned wages, tips, and net earning from self­employment over $1130 a month or performed 
substantial services in self­employment in all months of 2008: NO 
Months did not earn over $1130: January and June 
Total of all wages and tips expected in 2009: $22000 
Expected wages, tips, and net earnings from self­employment over $1130 a month or from 
performing substantial services in self­employment in all months of 2009: NO 
Months will not earn over $1130: January, March and June 
Total earnings include any special payments paid in one year but earned in another: NO 
Other Pensions/Annuities 
Ever worked in a job where Social Security taxes were not deducted or withheld: YES 
Receiving a pension or annuity based on this non­covered work: YES 
Pension or annuity based on government employment: YES 
Worked on railroad 5 years or more: YES 
Receiving or eligible to receive a railroad pension or annuity: YES 
Spouse worked for railroad 5 years or more: YES 
Spouse receiving eligible to receive railroad pension or annuity: YES 
Worked for federal government in 1983: YES 
Spouse worked for Federal Government in 1983: YES 
Direct Deposit Details 
Bank routing number: 001520633 
Account number: 009979955285 
Account type: Checking 
No account: No 
Benefit Information 
Filed for Supplemental Security Income: NO 
Intend to file for Supplemental Security Income: YES 
Previous application for Medicare, Social Security Benefits, or Supplemental Security Income 
(SSI) benefits: YES 
Types of Benefits: Medicare, Social Security, Supplemental Security Income 
Previous filing on your own Social Security Number: NO 
Name and Social Security Number of person(s) on whose record previously applied: 
Joe Public 999­99­9999 
Bill D. Blocks 990­90­9099 
Enrolled in Medicare Part B: NO 
Want to enroll in Medicare Part B: NO

Claim #: 999­99­9999 

Page 13 of 18 

Enrolled on own SSN: NO 
Receiving Medicaid: NO 
Covered under a group health plan: NO 
Ability to Work 
Limiting illnesses, injuries, or conditions: BROKEN BACK, HIGH BLOOD PRESSURE 
Blind: NO 
Work­related illnesses, injuries, or conditions: YES 
Now able to work: YES 
Date became able to work: 09/ 2000 
Disability Payments 
Filed or intend to file for workers’ compensation or other public disability benefits: NO 
Reason for not filing: I RECEIVE ENOUGH ALREADY – 
Received money from your employer on or after date became unable to work: YES 
Amount of pay received: 11234.50 
Type of pay received: SICK, VACATION, OTHER 
Expect to receive future payment from employer: YES 
Amount of future payment from employer: 13345.90 
Type of future payment from employer: SICK, VACATION, OTHER 
Dependents 
Has parent who receives one­half support from you: YES 
First Parent’s Name: John Doe Public 
First Parent’s Address: 123 Main Street, Gwynn Oak, MD 21207 
Second Parent’s Name: Roberta Lee Public 
Second Parent’s Address: 321 South Main Street, Liberty, MD 21044 
Number of years without earnings while caring for child under age 3: 6 
Years with no earnings: 1998, 1999, 2000, 2001, 2002, 2003, 2004 
Authorization 
Authorized disclosure of medical information: YES 
Receive reduced retirement benefits while waiting for disability decision: YES 
Remarks:
______________________________________________________________________________
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Claim #: 999­99­9999 

Page 14 of 18 

I declare under penalty of perjury that I have examined all the information on this
application and it is true and correct to the best of my knowledge. 
Signature _______________________________ 

Date________________________ 

Witnesses are required only if this application has been signed by mark (x) above. If
signed by (x), two witnesses to the signing who know the applicant must sign below,
giving their full addresses.
_____________________________
Signature of Witness

_____________________________
Signature of Witness

_____________________________
Number and Street Address

_____________________________
Number and Street Address

_____________________________
City, State, and Zip Code

_____________________________
City, State, and Zip Code

This form should be submitted to the address shown on your notice.
Privacy Act Statement
The Social Security Administration (SSA) is allowed to collect the facts on this form
under Section 205 of the Social Security Act. We need this information to efficiently
process your application. Giving us this information is voluntary. However, without
them we may not be able to process your application. While the information you
furnish on this form would almost never be used for any purpose other than the
intended use of this form, such information may be disclosed by SSA as generally
permitted under 5 U.S.C. sec. 552a(b) of the Privacy Act of 1974, as amended. This
includes using the information as necessary for administrative purposes or as
authorized by routine uses in the applicable Privacy Act system of records. SSA
has access to the information you provide on this application and is authorized to
keep even information on applications that were partially completed. This is for
purposes of helping you complete the application process. Explanations about
possible reasons why information you provide us may be used or given out are
available upon request from any Social Security office.
Paperwork Reduction Act Statement
Paperwork Reduction Act Statement ­ This information collection meets the
requirements of 44 U.S.C. sec. 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to review, confirm or sign this application
summary unless we display a valid Office of Management and Budget control
number; the control number is xxxx­xxxx. We estimate that it will take about 20
minutes to read the instructions, review the information contained in the summary,
and sign the application. You may send comments on our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235­6401. Send only comments relating
to our time estimate to this address, not the completed form.

Claim #: 999­99­9999 

Page 15 of 18 
{ Sample Return mailing address sheet }

Mailing Instructions
Re­fold and insert this page so the mailing address below can be clearly seen
through the address window of the reply envelope. Fold the application summary,
along with any additional pages required, and place them in the return envelope
behind this page. 

[DEVELOPER INSTRUCTIONS – PUBLIC WILL NOT SEE THIS] 
Attn: DEADA ‐  Position SSA office mailing address to be 
visible through window of the enclosed outgoing reply 
envelope. 

______________(1b)_______ 
______________(1c)_______ 
___(1d)_______(1e)__(1f)___ 

IMPORTANT
To ensure your application reaches Social Security,
re­fold this page along the dashed line above and insert so the
mailing address can be clearly seen through the window of
the reply envelope. 

[DEVELOPER INSTRUCTIONS – PUBLIC WILL NOT SEE THIS] 
Attn: DSUSF ‐  Position the graphic overlay (containing dashed line, 
arrows and the textbox below the dashed line) so that the heavy 
dashed line appears in the middle of the page to ensure that when 
folded, the address will appear properly in the envelope window.

Notice #2 ‐  Fill‐ins 

Fill‐in 1b‐1h 
Fill 1b‐1h with the following items for the claimant’s servicing field office as derived from the 
claimant’s zip code. 
1b – mailing address 
1c – mailing address, line 2 
1d – City 
1e – State 
1f – Zip Code 
1h ‐ phone number 
Fill‐in 2 
Date of notice: Calculate and display the batch run date plus 7 calendar days. 
(Format: Month DD, YYYY) 
Fill‐in 3 
System generated 8‐digit Confirmation Number 
Fill‐in 4a – 4f 
Applicant name and mailing address 
4a – name of applicant Format: First MI/Middle Last 
4b – mailing address 
4c – mailing address, line 2 
4d – City 
4e – State 
4f – Zip Code 
Fill‐in 5 
Name of third party who started the Internet application. 
Format: First MI/Middle Last, Suffix (use a “Special K” UTI) 
Fill‐in 6 
If organization exists display a variable length fill‐in for name of the organization with which the 
third party is associated. 
[Display “of ___________” if organization exists.] 
Fill‐in‐7 
Month, day and year the third party started the Internet application. (Format: Month DD, YYYY)

Fill‐in 8 
Month, day and year the third party completed the Internet application. 
(Format: Month DD, YYYY) 
Fill‐in 9 ‐ Closeout date: 
If Conditional Notice #1 was previously sent: 
Calculate and display the closeout date (equal to 6 calendar months plus 7 calendar days 
after the start date of the ISBA application. 
(Format: Month DD, YYYY). The 6‐month interval is equal to 6 calendar months and not 
180 days. (E.g.: Six months from Jan 15th will be July 15 th . Seven additional calendar 
days are then added, and if that day falls on a non‐business day (weekend or holiday), 
then add days until the next business day is been reached. 
If Conditional Notice #1 was not previously sent: 
Calculate and display the closeout date (equal to 6 calendar months plus 7 calendar days 
after the completion date of the ISBA application (Format: Month DD, YYYY). The 6‐ 
month interval is equal to 6 calendar months and not 180 days. (E.g.: Six months from 
Jan 15th will be July 15 th . Seven additional calendar days are then added, and if that day 
falls on a non‐business day (weekend or holiday), then add days until the next business 
day is been reached. 
Fill‐in 10 
Complete address of the third party (street address, street address line 2, city/state/zip code) 
in‐line as single comma separated string. 
Fill‐in 11 
Telephone number of the third party, including area code and extension if exists. 
Fill‐in 12b ‐ 12f 
Use the physical location of the claimant’s servicing field office as derived from the claimant’s 
zip code. 
12b – mailing address 
12c – mailing address, line 2 
12d – City 
12e – State 
12f – Zip Code 
Fill‐in 13 
Complete SSN of the applicant 
Fill‐in 14 
Calculate the SSI closeout period as follows: 
If Conditional Notice #1 was previously sent: 
The closeout period starting date begins seven calendar days after generation of the 
Application Number (start date of the ISBA) and ends 60 calendar days after that date.

(Format: Month DD, YYYY). If the ending date falls on a non‐business day (weekend or 
holiday), then add days until the next business day has been reached. 
If Conditional Notice #1 was not previously sent: 
Calculate and display the SSI closeout date. The closeout period starting date begins 
seven calendar days after the ISBA application was completed. If the ending date falls 
on a non‐business day (weekend or holiday), then add days until the next business day 
has been reached. 

Notice #2 ‐ Conditional Text Blocks 

C1 – Include only if the “List of Acceptable Evidence” document is printed and inserted 
C2 – Include only if the third party answered “Yes” to the ISBA disability question triggering 
printing and inserting the Medical Release form (SSA‐827s) 
C3 ‐ Include only if the SSA Office’s physical address is different than the mailing address 
C4 – Only include if ISBA logic determines that SSI questions will be asked and if the third party 
answered “Yes” to the “intent to file for SSI” question. 
Rules for printing conditional text blocks C6 through C12 will be determined by the OSES 
analyst based on user responses to ISBA questions. 
C6 ‐ Proof of Age 
C7 ‐ Proof of Citizenship or Naturalization 
C8 ‐ Proof of U.S. Military Service Before 1968 
C9 ‐ Proof of Wages from Your Employer 
C10 ‐ Proof of Self‐Employment Income 
C11 ‐ Medical Evidence 
C12 ‐ Proof of Workers’ Compensation and/or Similar Benefits

ISBA Redesign/ISBA Third Party Enhancements 
{Printed Reply Envelope Reminders 
Notice #2}

REMINDERS:
·  Did you sign your application?
·  Did you properly insert the mailing instruction sheet so the address is clearly visible 
through the envelope window?
Sealing flap 

·  Did write your return address in the upper left­hand corner of the envelope?
·  Did you add the proper amount of postage? 
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