Form SSA-1 Application for Retirement Insurance Benefits

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Form SSA-1-BK (06-2018) UF

RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY RETIREMENT INSURANCE BENEFITS

TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT

BEFORE YOU RECEIVE A I SSA OFFICE
NOTICE OF AWARD

DATE CLAIM RECEIVED

AFTER YOU RECEIVE A
NOTICE FOF AWARD

Your application for Social Security benefits has been received
and will be processed as quickly as possible.

there is some other change that may affect your claim, you - or
someone for you - should report the change. The changes to be
reported are listed on page 8.

You should hear from us within___ days after you have
given us all the information we requested. Some claims may
take longer if additional information is needed.

Always give us your claim number when writing or telephoning
about your claim.

In the meantime, if you change your address, or if

If you have any questions about your claim, we will be glad to
help you.

CLAIMANT

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and
timely decision concerning your or a dependent's eligibility to benefit payments.
We will use the information you provide to help us determine your or a dependent's eligibility for benefit payments. We may also
share the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA)
in the efficient administration of its programs.
2. To student volunteers, individuals working under a personal services contract, and other workers who technically do not have
the status of Federal employees, when they are performing work for SSA, as authorized by law, and they need access to
personally identifiable information in SSA records in order to perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059, entitled Earnings
Recording and Self-Employment Income System and 60-0089, entitled Claims Folders System. Additional information and a full
listing of all our SORNs are available on our website at_www.soc1alsecurity",9Qv/foia/blueb0Qk.
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 11 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You
can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under
U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.