Current Version of SSA-455

FORM APPROVED
OMB O. 0960-0511

SOCIAL SECURITY ADMIISTRATIO

DISABILITY UPDATE REPORT
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R. 404.1589 and
416.989 authorize us to collect this information. We will use the information you provide to further document your claim and permit a
determination about continuing disability.
The information you furnish on this report is voluntary. However, failure to provide us with the requested information could prevent us from
making an accurate and timely decision on your claim.
We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security benefits. However, we may
use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency
in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability
Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by
other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's
eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information are available in our Systems of Records Notices entitled, Claims Folders Systems (60-0089)
and the Master Beneficiary Record (60-0090). These notices, additional information regarding this form, routine uses of information, and our
programs and systems are available on-line at www.socialsecurity.gov or at your local 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
(OMB) control number. The OMB control number for this collection is 0960-0511. We estimate that it will take 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.

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.

/

/

$

Form SSA-455 (10-2011)

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

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.
Date
Telephone Number
Sign


Here
Form SSA-455 (10-2011)