Form SSA-455 Disability Update Report

FORM APPROVED
OMB NO. 0960-0511

DISABILITY UPDATE REPORT
PRIVACY ACT/PAPERWORK ACT NOTICE: The information requested on this form is authorized by the Social Security Act, Sections
205 (a) and 1631 (e) (1) (A) and (B), and regulations at 20 CFR 404.1589 and 416.989. The information provided will be used to futher
document your claim and permit a determination about your continuing disability. Information requested on this form is voluntary. However, if
you do not provide the required information, a decision based on the evidence in your file can result in a determination that your period of
disability is ceased. While the information you furnish on this form would almost never be used for any purpose other making a determination
about your disability, such information may be disclosed by SSA for the following purposes: (1) To assist SSA in determining the right to Social
Security benefits for yourself or another person; (2) To facilitate statistical research and audit activities necessary to assure the integrity and
improvement of programs administered by the Social Security Administration and another agency. Explanations about these and other reasons
why information you provide us may be used or given out are available in the Social Security offices. If you want to learn more about this,
contact any Social Security office.
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
control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the nearest office, call 1-800-772-1213. Send only
comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401.

Name and Address

Claim Number

1. Within the last 2 years have you worked for someone or been self-employed?
Yes
No
If yes, please complete the information below.
Work Began
(month/year)

Work Ended
(month/year)

Monthly
Earnings

1.

/

/

$

2.

/

/

$

3.

/

/

$

2. Check the block which best describes your health within the last 2 years:
Better
Same
Worse
3. Within the last 2 years has your doctor told you that you can return to work?
Yes
No

Form SSA-455 (8-2002) Destroy Prior Editions

4.

Within the last 2 years have you attended any school or work training program(s)?
Yes

No

5.

Would you be interested in receiving rehabilitation or other services that could help you
get back to work?
Yes
No

6.

Within the last 2 years have you been hospitalized or had any surgery?
Yes

No

If yes, please list below:
Reason

Date: (month/year)

1.
2.
3.
7.

Within the last 2 years have you gone to a doctor or clinic for your condition?
Yes
No

If yes, show the date and the reason for the visit.
1. Date
Reason
2. Date
Reason
3. Date
Reason
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 correct 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.
SIGN
HERE
Form SSA-455 (8-2002)

Date

Telephone Number