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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 1-800772-1213 (TTY 1-800-325-0778).
State Agency that requested it. If you need the address or phone number for your State. Agency, you can get it by calling 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.
31 sty 2021 · OMB 0960-0578. SSA collects the information to document an applicant's work history. The Disability Determination Services adjudicators use the information to make a decision about the alleged disability. The respondents are applicants for disability benefits.
OMB No. 0960-0578. WORK HISTORY REPORT. PLEASE READ ALL OF THIS INFORMATION BEFORE COMPLETING THIS REPORT. The office that makes the disability decision on your case will use the information you provide in this report to understand how your illnesses, injuries, or conditions might affect your ability to do work for which you are qualified.
Applicants use Form SSA-3369, Work History Report, to provide SSA with detailed information about applicant’s jobs held prior to becoming unable to work. State Disability Determination Services evaluate the information together with medical evidence, to determine eligibility for disability payments.
Edit, sign, and share ssa form omb no 0960 0578 online. No need to install software, just go to DocHub, and sign up instantly and for free.
If you have questions about how to complete the form, contact the State Agency that requested it. If you need the address or phone number for your State Agency, you can get it by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
