Job Title Type of Business Dates Worked From Form SSA-3369-BK 04-2014 ef 04-2014 PAGE 1 Destroy Prior Editions To C. WORK HISTORY REPORT- Form SSA-3369-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP If you need help with this form complete as much of it as you can. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form for help to finish it. There is a separate page to describe each different job. REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 8 Work History Report -- Form SSA-3369-BK HOW TO COMPLETE THIS FORM Privacy Act Statement Collection and Use of Personal Information Sections 205 a 223 d and 1631 e 1 of the Social Security Act as amended authorize us to collect this information. We will use the information you provide to make a determination of eligibility for Social Security benefits. The information that you give us on this form will be used by the office that makes the disability decision on your disability claim* You can help them by completing as much of the form as you can* Print or type. A reference to you your or the Disabled Person or claimant means the person who is applying for disability benefits. If you are filling out the form for someone else provide information about him or her. ANSWER ALL OF THE QUESTIONS FOR EACH JOB YOU DESCRIBE* If you do not know the answer or the answer is none or does not apply please write don t know or none or does not apply. Be sure to explain an answer if the question asks for an explanation or if you think you need to explain an answer. If more space is needed to answer any questions use the REMARKS section on Page 8 and show the number of the question being answered* WHY THIS INFORMATION IS IMPORTANT conditions might affect your ability to do work for which you are qualified* The information tells us about the kinds of work you did including the types of skills you needed and the physical and mental requirements of each job. In Section 2 be sure to give us all of the different jobs you did in the 15 years before you became unable to work because of your illnesses injuries or conditions. Furnishing us this information is voluntary. However failing to provide us with all or part of the information may prevent an accurate and timely decision on any claim filed* We rarely use the information you supply us for any purpose other than to make a determination regarding benefits eligibility. However we may use the information for the administration of our programs including sharing information 1. To comply with Federal laws requiring the release of information from our records e*g* to the Government Accountability Office and Department of Veterans Affairs and 2. To facilitate statistical research audit or investigative activities necessary to ensure the integrity and improvement of our programs e*g* to the Bureau of the Census and to private entities under contract with us.
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How to prepare Form SSA-3369-BK
What Is form ssa 3369 bk?
Form SSA 3369-BK is a Work History Report. This legal document is usually submitted to the Social Security Administration and helps to determine how your medical condition affects your ability to work in jobs for which you’re qualified. The report shows the responsibilities a person has performed in the past as well as skills and experience he/she has gained during employment.
This report helps the SSA to determine whether an individual is able to perform any kind of activity for which he/she may be qualified. The details provided mean not only a person cannot work in the last job, but also that he/she doesn’t have enough knowledge, skills or experience to find job in another area.
On this website you will find a fillable SSA 3369-BK sample in PDF that effortlessly can be completed online. The form consists of three sections that should include the following:
data about a disabled person, i.e. name, contact details and SSN;
information about work (here pryour job title, type of business, dates worked, description of responsibilities, rate of pay and other related details);
name of a person who completes a form if other than a disabled;
date of creating;
address and e-mail.
If you lack of space in other parts of a sample, there is one additional page where you can include all the important data. You also have an ability to edit a blank according to your requirements using various editing tools. Each sample is printable, so you can easily print it out. If you fill out a template online, you can send to a recipient straight from the source by e-mail.
Online choices make it easier to prepare your document administration and enhance the productiveness of the workflow. Carry out the fast manual for you to finished Form SSA-3369-BK, stay clear of glitches and furnish it in the well timed method:
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