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DATE:
Disability Update Report
Social Security Administration, P.O. Box
FORM APPROVED
OMB NO. 0960-0511
, Wilkes-Barre, PA 18767
PAYEE’S NAME AND ADDRESS
REPORT PERIOD
From:
BENEFICIARY
To The Present
PSC:
TELEPHONE NUMBER
1.
a. Since
CLAIM NUMBER
YES
, have you worked for someone
NO
➤
or been self-employed?
b. If you answered “YES” to 1.a., please complete the information below.
WORK ENDED
Month
Year
WORK BEGAN
Month
Year
Most
Recent
Work
2.
1.
$
,
2.
$
,
3.
$
,
Have you attended any school or work training program(s)
since
3.
YES
NO
?
to the present...(Please place an “X” in one box only):
Since
my doctor and I
have not discussed
whether I can work.
4.
MONTHLY EARNINGS
Dollars Only, No Cents
my doctor
told me I
cannot work.
my doctor
told me I
can work.
Place an “X” in only one box which best describes your health
now as compared to
BETTER
Form SSA-455-OCR-SM (10-2003)
.
SAME
Continued on the Reverse
WORSE
➤
FOR SSA USE ONLY
AC?
5.
a. Have you gone to a doctor or clinic for treatment
(including evaluations, checkups, counseling,
prescriptions, or medicine) since
?
YES
NO
➤
b. If you answered “YES” to 5.a., please list:
Reason For Visit:
Most
Recent
Visit
Month
Year
1.
2.
3.
6.
a. Have you been hospitalized or had surgery
since
?
YES
NO
➤
b. If you answered “YES” to 6.a., please list:
Most
Recent
Reason For Hospitalization or Surgery:
Month
Year
1.
2.
3.
REMARKS: If you use this space to further answer questions 1. through 6.,
place an “X” in the box to the right and print on the lines below.
SIGN HERE
➧
Form SSA-455-OCR-SM (10-2003)
TODAY’S DATE
TELEPHONE NUMBER (include Area Code)
| File Type | application/pdf |
| File Title | MultiPage PDF File |
| Author | Rampage Systems, Inc. |
| File Modified | 2011-05-19 |
| File Created | 2009-07-06 |