Sample SSA Forms
Appendix D contains samples of SSA forms that were mentioned throughout the text of the manual as being necessary or helpful to the process of applying for disability benefits. The following forms are included in this appendix:
PLEASE NOTE: The actual manual contains copies of the following forms therefore there is not a text/html equivalent for the forms. Please refer to the Adobe PDF version of this document to view the images of the forms by clicking here.
- Form SSA-8000-SSI Application
- Form SSA-3368-Disability Report for Adults
- Form SSA-3369-Work History Report
- Form SSA-1696-Appointment of Representative
- Form SSA-561-Request for Reconsideration
- Form SSA-827-Authorization to Disclose Information to SSA
- Form SSA-787- Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits
- Form HA-501-Request for Hearing by Administrative Law Judge
- Form HA-520-Request for Review of Decision/Order of ALJ