Form SSA-546 Workers' Compensation/Public Disability Benefit Questinn

Social Security Administration

Form Approved
OMS No. 0960-0247

WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT QUESTIONNAIRE
NAME OF WORKER

_ _ _ _ _ _.J...IS~O_C_I_AL SECURITY NUMBER

Privacy Act Statement
Collection and Use 01 Per.onallnlonnation

"TU
fn

ded, authortz
Ilc disability ben.f, on your Soc,al

Section 224 of the SocIal ecurrty Act, as am

compensat,on or other p

olunlary He ever. f

but are not limit
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To

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to the following:
ble a third party

tcomPIY
fairs!,

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SSfst

SOCIiI Secunty

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In

the effect of your w."rker's

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auld pr.vont an accuralo 0tm.IY doclS,on on your cl.,lnd could affect your

y for any purp sa other than for d;t.8ter tmng the effect of other dl
cuflty progra s W. may afso dlscio InformatIon to another per
an agency to

Id~termlne

soe~secunty

Howeve~,

bll,ty benefits on your
benefits
w e may use It for the
or to another agency In a cordanoe with approved rou ne us.s, which Include

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stabhshmg rights to SOCIal sfcuntY bernlftts andior cover,ge;

wIth FZderI laws reQUlnnlth. r.I•••• of .nformat.oh from Soc,.1 Secunty r.cord} I. g • to th. Governmont A!countab,hty Offlc. and Depalm.nl of Veteran.'

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Statement

proVIde will be used to

I.on. for ells' Ity

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Slm,lar health and ./om. malnlenance programs /the Fed.ral. state and 10c./evol, and

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To tac,lIlate Of 'st,c.1 r••••rc • aud'l or IOvesl'gative oct../;"e. necessary to ••sure th. flegnty of Soc,al SocufllV pfsrams

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We
y also use the i ormation you ovid, in computer matchi1J9 programs, Matching program& compare our records with records kept by other Federal, state or local government
ag eles. Information rom these ma hing programs can be used to establish or verify a person" eligibility for Federally funded or administered benefit programs and for repayment of
pa ments or deltnqu nt debts under these programs.
Additional information regarding this form, routine useS of information. and

at www.ssa,gov or at your local Social Security office.

Paperwork Reduction Act Stetement ~ This infor tion collection meet
~nded by sectlO~2of the~rk d ·
f 19 ,1- You do
not need t9"'answer thiS6uestions unless we !splaya valid Office of Ma
estimate that it wi( tak.e about 12.5 minutes to read the in ructions.
gather thlfaats, and an er the questions.
ND OR BRING THE COMPl
CURJTY OFFtCE.
e office i.listed under U, S. Gov.rnm t agencies
in your telephone dirac ry or you may call S ·al Security et 1w800·772.121-",'~~_ _ _~_~_ _.,..,j\lnd comment. on r tima estimate above to: SSA 6401Sacurity Blvd.
Baltim ...... MO 2123 -6401. &Inti f'!l!:r.
mmtmt. ",lBting 10 our limtJuti
lid form.
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1. What type of benefit are you rBceiving. did you receive or do you expect to receive in connection with your disability?
WORKERS' COMPENSATION:
Workers' Compensation - State (including)
occupational disease payments)

o
o

o

PUBLIC DISABILITY BENEFITS:

Civil Service Disability or Federal Employees' Re­

tirement System (FERS) Disability Benefits

O

o
o

Black Lung Benefits
Longshore and Harbor Workers' Compensation

State Temporary Disability Payments

Federal, State or Local Government

Employee Disability Benefits
DOther: _ _ _ _ _ _ _ _ _ _ _ _ _ __

Federal Employees' Compensation (FECA­
workers' compensation for Federal employees)

2 For each benefit checked above , enter the claim number employer, insurance carrier and date of injury/illness.
TYPE OF BENEFIT
CLAIM NUMBER
EMPLOYER
INSURANCE CARRIER

DATE OF INJURY/ILLNESS

i
3. Indicate the State in which you worked when these benefits began or: i.f workers'
, the InJu r y oc curred.
. .IS one of the benefits
. Involved,
.
the State .
In which
compensation

I

STATE

4. If you are receiving one of the public disability benefits listed in item 1, were Social Security taxes always paid on your eamings?

0

DYes

No

(If "No," explain. For example, you were a federal. State or local government employee whose earnings
were not covered or were not always covered by Social Security.)

5, Indicate the status of your claim for workers' compensation or other public disability benefits. If you are receiving more than
one type of benefit. indicate the status of each claim.

Filed for Benefits, or Intend to File but not yet
Entitled

d,

b.

Filed for Benefits. but Claim was Denied

e.

c.

Claim Denied; Appeal Pending lif appeal is pend- ing.
give date you expect a decision.)
Date

f.

o

Currently Receiving Benefits
Received Payments in the Past but not Presently

o

Other (e.g., lump-sum payment) Explain:

If a., b .. or c. is checked, go on to Item 11 (signature block). If d.• e., or f. is checked. complete the remainder of the form.
6. How are (or were) those disability payments made?

o

Weekly

o

Monthly

DEvery Two Weeks

o

FORM SSA-546 (4-2009) EF (4-2009) Destroy prior editions

Other (Explain):

-

7. a. List the amount(s) and the period(s) of time for which those disability benefits were made. (if only lump-sum payment was
made , see item 8 )
TYPE OF BENEFIT

AMOUNT

FROM

TO

b. If those payments have stopped, indicate the reason.
D

Appeal Pending

Lump-Sum Settlement Pending
Permanent Rating Pending

c. Do you expect those payments to begin again?

D
DYes

Other (Explain in item 10, "Remarks")
No

IF "YES", WHEN (Date)

8. Have you ever received or been awarded a lump-sum settlement (including
"compromise and release" or similar type of settlement)? _ _ _ _ _ _ _ _ _...
9. Lump-sum payment:
a. Datels) settlement/s) or award/s) made

Yes (If "Yes",
complete item 9)

No

b. Gross Amount/s)

$
c. The lump sum represents:

$

per week for

weeks beginning

d. The amount shown in 9.b. (Gross amount) includes:
11) MEDICAL EXPENSES OF

12) ATTORNEY FEES OF

$

$

13) RELATED EXPENSES OF

$

10. Remarks:

IMPORTANT INFORMATION. PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW
I agree to report if I apply for or begin to receive a workers' compensation (including black lung benefits) or a public
disability benefit or the amount that I am receiving changes or stops, or I receive a lump-sum settlement. I understand
that such benefits may affect my Social Security payments or result in an overpayment which I may have to pay back.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correc~ to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information. or causes someone else to do so. commits
a crime and may be sent to prison. or may face other penalties. or both.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First Name. Middle Initial, Last Name) (Write in Ink)

SIGN

HERE

.....

DATE
TELEPHONE NUMBERS/S) at which
you may be contacted during the day

~

MAILING ADDRESS (Number Street. Apt. No., P.O. Box" Rural Route)
CITY AND STATE

IZIP CODE

Witnesses are required ONLY if this form has been signed by mark (X) above. If signed by mark (Xl. two witnesses to the
signing who know the person requesting reconsideration must sign below. giving their full addresses.
(1) SIGNATURE OF WITNESS
(2) SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State and ZIP Code)

FORM SSA·546 (4-2009) EF (4-2009)

ADDRESS (Number and Street, City, State and ZIP Code)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this
collection is 0960-0247. We estimate that it will take between 15 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.