DISABILITY APPLICATION

 Thank you again for your time on the phone today. Below are the
required forms that must be signed in order for us to represent
you on your disability claim. Please review and sign each
document. Once you have completed your documents, we can
then work on filing your application.

 Each required document will have an explanation prior to signing

if you have any questions.

 After completing this document, we will either continue to gather

your medical and work history over the phone to complete your
application, or we will need to call you back to gather this
information.

 If we will be calling you back to finalize your application, you will

receive another email to begin providing us with your medical and
work history.

 If you have any questions that cannot be answered within this

document, please do not hesitate to call us at 1-800-652-9626.

 You can click “Start” or “Resume” to jump straight to the first

place you need to sign. After, click “Next” or the blue arrow
buttons to jump to new signature lines.
 LIMITED
POWER OF ATTORNEY

 This document allows our office to date documents on your

behalf, including medical release documents.
 This document allows our office to add any omitted dates and
correct any typos on your behalf.
 Should any additional services become available, this document
allows us to contact you and discuss these services should you
want them.
 Limited Power of Attorney and Disclosures
Page 1

Claimant: Biaca Bush SSN: 430-69-8798

I grant to Trajector Disability, or their agents or assigns, limited power of attorney to collect my medical
information for purposes of my Social Security Disability matter as follows:

HIPAA Release Authority.

I grant authority to Trajector Disability, or their agents or assigns, access, use and disclosure of my individually
identifiable health information or other medical records. I further authorize Trajector Disability, their agents or
assigns to sign and/or date any medical release document on my behalf as it may be necessary to collect my
medical information as part of my ongoing Social Security Disability matter. This release authority applies to
any information governed by the Health Insurance Portability and Accountability Act, 42 USC 1320d and 45
CFR 160-164.

Legal Consent for Disclosure of Health Care Information.

Any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other
health care provider, any insurance company, the Medical Information Bureau Inc. or other health care
clearinghouse that has provided treatment or services shall give, disclose and release to Trajector Disability, or
their agents or assigns, without restriction, identifiable health information and medical records regarding any
past, present or future medical or mental health condition.

Legal Consent for Disclosure of Specific Mental Health Care Information.

Any psychologist, psychiatrist, licensed therapist or other healthcare provider involved with diagnoses or
therapy or other treatment of me which pertains to my mental health shall disclose and release to Trajector
Disability, their agents or assigns, any and all individually identifiable health information and medical records
involving any past present or future mental health condition.

Supersession of Prior Documents and Expiration Event.

This authority given to Trajector Disability, or their agents or assigns, in this legal consent form shall supersede
any prior agreements that I may have made with my health care providers to restrict access or disclosure of my
individually identifiable health information. The authority given to Trajector Disability or their agents or
assigns expires when they cease to represent me as part of my Social Security Disability matter or when I
revoke this authority in writing and deliver it to the same.

Release and Hold Harmless Provision.

In order to induce the disclosing party to disclose the aforesaid private and/or protected confidential
information, I forever release and hold harmless said disclosing party who relies on this instrument from any
liability under confidentiality rules arising from HIPAA as a consequence of said disclosure.

Authorization to Add Omitted dates and Correct Typographical or Clerical Errors.

I authorize Trajector Disability to date documents on my behalf, including medical release documents to obtain
my medical records, Appointment of Representation, Social Security Fee Agreement, Consent to Release
Information, Direct Payment Authorization, or any other SSA paperwork necessary for processing of my
disability claim with the Social Security Administration. I further authorize Trajector Disability to correct
clerical or typographical errors on documents on my behalf.

(TD 11-2023)
 Limited Power of Attorney and Disclosures (Page 2)
Claimant: Biaca Bush SSN: 430-69-8798

Provide Trajector Disability with Current Contact Information and Authorization to Contact. I
understand how important it is for me to stay in contact with Trajector Disability so I can be informed about
important developments in my Social Security disability case and to help Trajector Disability by providing
necessary information to process and/or appeal my claim. By signing below, I agree to update Trajector
Disability as soon as possible if there are any changes to my contact information. I further agree to be contacted
by Trajector Disability or their agents or assigns, and authorize direct contact or calls from email messages,
MMS messages, SMS messages, an automatic telephone dialing system, an artificial or prerecorded voice,
prerecorded voice messages, or postal mail at my residential or cellular phone number.

Choosing the Manner and Appearance for a Hearing

If my case is appealed to the Office of Hearings Operations (OHO) for a hearing with an Administrative Law
Judge (ALJ), I authorize Trajector Disability to choose on my behalf the manner and appearance for a hearing
based on their professional judgment. Absent extraordinary circumstances, I consent to a phone or online video
hearing.

File Retention.
Although we may create and/or obtain paper documents on your behalf, we will store those documents as digital
copies only. Please do not send us original versions of vital records such as birth or death certificates, deeds,
wills, etc. At the conclusion of our representation, if we have documents related to your case such as medical
records, RFCs, etc., we will provide them to you after confirming your mailing address. Unless you instruct us
otherwise, we will retain your file for a period of six years after which it will be destroyed under the terms of
our File Retention Policy.

Disclosure that Trajector Disability may Offer Additional Services.

From time to time, Trajector Disability comes across other goods and services that they feel I may be interested
in. I authorize Trajector Disability or its related businesses to contact me to let me know about these services.
In the event that I request to learn more about these services, I authorize Trajector Disability to share
information relating to my Social Security Disability claim as necessary to discuss or obtain these services. I
understand that Trajector Disability has or may have a financial interest in services they inform me of and that I
don't have to use these services. If I am interested and have questions, I understand that I can consult my
attorney, tax professional or business adviser.

I recognize that my medical information is private and further authorize Trajector Disability to communicate
with the following individuals regarding my claim: (i.e. spouse, parent, friend)

Name Relationship Phone Number

{{C1Name_es_:signer1}}
Brigette Houston {{C1Rel_es_:signer1}}
Cousin {{C1Ph_es_:signer1}}
501-838-9547

{{C2Name_es_:signer1}} {{C2Rel_es_:signer1}} {{C2Ph_es_:signer1}}

Miss Biaca Nicole Bush

{{Sig_es_:signer1:signature}}
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)
{{Date_es_:signer1:date}}
Jul 2, 2024
___________________________________ __________________________
Claimant Signature Today’s Date (MM/DD/YYYY)

(TD 11-2023)
 SSA-1696:
APPOINTMENT OF
REPRESENTATIVE

 This document legally appoints our office as the representative on

your disability claim.
Form SSA-1696 (08-2020) UF
Discontinue Prior Editions Page 1 of 6
Social Security Administration OMB No. 0960-0527

Instructions for Completing Form SSA-1696

Keep a copy of this form for your records
DO NOT FILE form SSA-1696 if you do not have a claim, you are not filing a claim with this form, or there is no other
issue pending decision with us. In this document, “you” means the claimant, beneficiary, auxiliary or spouse. “Us” and “SSA”
means the Social Security Administration.
General Information About This Form
• You have the right to appoint a qualified representative of your choice to represent you on any claim or asserted right under any
of our programs. For more information on who can qualify to be an appointed representative, when your representative's
appointment begins or ends, payment of fees to appointed representative(s), and other helpful information, or to locate your local
field office, you can visit our website at www.ssa.gov/locator. Call us, toll-free, at 1-800-772-1213.
• You and your representative(s) may use this form to start the representation. Your representative may also use this form to
waive a fee, waive direct payment of the fee, or tell us that a third party will pay the fee.
• You may also choose to be unrepresented. We handle your case in the same manner whether you are represented or
unrepresented. You do not need to appoint someone who simply helps you through the process. For example, you do not need
to appoint someone who helps you come to our office, reads to you from documents, or interprets for you if you speak another
language. You only need to appoint someone if he or she will be acting or appearing on your behalf, or will be making decisions
about your case for you.
• You and your representative(s) must give us accurate information as quickly as possible. Providing misleading or false evidence
on this form or your application, or withholding or delaying giving us evidence, could lead to possible criminal charges or
administrative sanctions against you or your representative.

Appointing a Representative
If you are using this form to appoint a representative, you must complete Sections 1, 2, and 3. Your representative must complete
Sections 5 and 7 of this form. Both you and your representative must complete Section 4, either of you can complete section 6.
You or your representative must file the completed form with us, in-person at your local field office, by mail, or by fax. Review and
complete all required sections. If you are appointing multiple representatives, use separate forms for each representative. Your
representative or someone else can help you complete the form but you must sign and date Section 8. Your representative must
also sign the form if he or she is a non-attorney. You or your representative must submit the completed form to us before we will
recognize your representative. You can file it in-person at your local field office, mail it, or fax it to us. Do not file this form with your
local State Disability Determination Services office.
Section 1 - Claimant's Information and Number Holder's Information
Complete all of the information, including your Social Security Number. If you are filing your claim on someone else's Social
Security record, this person is the “number holder” and we need his or her information to process your claim.

Section 2 - Authorization for Disclosure

By selecting the disclosure box, you are authorizing us to give information to your representative's staff, partners, associates and
other individuals who work for or with your representative (such as contractors and copying services). We will check the
credentials of the individuals requesting information on behalf of your representative for authentication purposes.

Section 3 - Principal Representative

If you appoint or have appointed multiple representatives, you must name your principal representative who will be our main point
of contact. We will send copies of your notices to this individual and communicate directly with him or her.

Section 4 - Representative's Information

Both you and your representative must complete all of the information in this section. It is important to fill in all the boxes, including
the Representative Identification Number (Rep ID). Ask your representative for his or her Rep ID, if you do not know it. This box
should only be left blank if your representative does not have a Rep ID.

Section 5 - Representative's Status, Affiliations, and Certifications

Your representative must complete this section to let us know his or her status as a professional. If your representative is seeking
a fee and is working for an employer, entity or firm, he or she must also complete the affiliation section and give us the Employer’s
Identification Number (EIN). We will provide both your representative and the employer, entity, or firm with a copy of the form IRS
1099-MISC showing the reported income. For more information on form 1099-MISC and employer registration, visit our website at
www.ssa.gov/representation. Your representative should also certify the accuracy of all statements in this section.
Form SSA-1696 (08-2020) UF Page 2 of 6
Section 6 - Claim Type
Either you or your representative can complete this section. Check all types of claims for which you seek representation.

Section 7 - Fee Arrangement

Complete this section, if your representative is or will be asking for a fee for services performed on your claim. Generally, to
charge a fee for services, your representative must get our approval. Your representative may waive the right to charge you a fee
or tell us that a third party entity (business, government agency, or organization) will pay the fee. In these situations, the third party
must pay out of its own funds the fee and any expenses, and you and any auxiliary beneficiaries (e.g., children or spouse) must
be free of responsibility to pay any fees or expenses. If your representative is eligible for direct payment, he or she also may waive
the right to direct payment.

Section 8 - Signatures
You must sign and date this section. If your representative is not an attorney, he or she also must sign and date this section. We
also encourage attorneys to sign this section to confirm that they will abide by our rules.

Privacy Act Statement - Collection and Use of Personal Information

Sections 206 and 1631(d) 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 appointing a representative
to act on your behalf.

We will use the information to verify the appointment of your representative and his or her acceptance of the appointment. We
may also share your information for the following purposes, called routine uses:

• To a congressional office in response to an inquiry from that office made on behalf of, and at the request of, the subject
of the record or a third party acting on the subject’s behalf;

• To Federal, State, and local law enforcement agencies and private security contractors, as appropriate, information
necessary:

(a) to enable them to protect the safety of Social Security Administration (SSA) employees and customers, the
security of the SSA workplace, and the operation of SSA facilities; or
(b) to assist investigations or prosecutions with respect to activities that affect such safety and security or
activities that disrupt the operation of SSA facilities; and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient administration
of its programs.

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) 60-0089, entitled Claims
Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0320, entitled Electronic
Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210; and 60-0325, entitled Appointed
Representative File, as published in the FR on October 8, 2009, at 74 FR 51940. Additional information and a full listing of all our
SORNs are available on our website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement

This information collection meets the clearance 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 30 minutes to read the instructions, gather the facts, and answer the questions.
You may send us your comments on our estimated completion time to SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Send only comments relating to our time estimate to this address, not the completed form.

References
• 18 U.S.C. §§ 203, 205, and 207; 42 U.S.C. §§ 406, 1320a-6, 1383(d)(2) and 1631;
• 26 U.S.C. §§ 6041 and 6045(f) and 20 CFR §§ 404.1700 et. seq. and 416.1500 et. seq.
Form SSA-1696 (08-2020) UF
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Social Security Administration OMB No. 0960-0527
Claimant's Social Security Number Appointed Representative's Rep ID

4 3 0 - 6 9 - 8 7 9 8 5 R Z 7 Y Z 7 P F S

Claimant's Appointment of a Representative

Section 1 - Claimant's Information
First Name Initial Last Name

Biaca N Bush
Mailing Address

2124 Labette Manor Dr Apt L14

City State ZIP/Postal Code Country - if outside the U.S.

Little Rock AR 72205

Phone Number Alternate Phone Number (Optional)

501 940-4324
Country/Area Code Phone Number Country/Area Code Phone Number

Number Holder's Information (Complete when applicable)

My claim is based on another person’s work or earnings (e.g., spouse or parent). This person’s information is different from mine.
Number Holder's Social Security Number

- -
First Name Initial Last Name

Section 2 - Disclosure (Claimant Only)

By selecting this box, I, the claimant listed in Section 1, whose signature appears in Section 8, authorize SSA to release
information in relation to my pending claim(s) or asserted right(s) to designated associates who perform administrative duties
(e.g., clerks, assistants), partners, or parties under contractual arrangements for or with my representative. (The appointed
representative’s partners, associates, delegates and designees must be prepared to provide information in order to be
authenticated.)

Section 3 - Principal Representative (Claimant only – Complete when applicable)

I have appointed before, or appoint now, more than one representative. I ask SSA to make contacts or send notices to this
individual. My principal representative is:

Name Merrick Jackson REP ID: 5RZ7YZ7PFS

Form SSA-1696 (08-2020) UF Page 4 of 6
Claimant's Social Security Number Appointed Representative's Rep ID

4 3 0 - 6 9 - 8 7 9 8 5 R Z 7 Y Z 7 P F S

Section 4 - Representative's Information (Claimant and Representative)

Representatives who are eligible and seek direct payment of their fee must register and receive a Rep ID before the appointment.
For more information about registration visit us on-line at www.socialsecurity.gov/ar, contact us at 1-800-772-1213
(TTY 1-800-325-0778), or visit your local Social Security office.
First Name Initial Last Name

Merrick Jackson
Mailing Address

PO BOX 127

City State ZIP/Postal Code Country - if outside the U.S.

LEHI UT 84043

Phone Number Alternate Phone Number (Optional)

801 766-5442
Country/Area Code Phone Number Country/Area Code Phone Number

Section 5 - Representative's Status, Affiliations, and Certifications (Representative Only)

Representative's Status Part A - Type of Representative (Representatives have a duty to keep their information current)

I am an attorney (SSA law states that an attorney is someone in good standing who has the right to practice law before a
court of a State, Territory, District, or island possession of the United States, or before the Supreme Court or a lower
Federal court of the United States.)

I am a non-attorney eligible for direct payment (SSA law requires that non-attorneys meet certain criteria to qualify for direct
payment. Refer to our website at www.ssa.gov/representation for criteria).

I am a non-attorney not eligible for direct payment.

I work for a non-profit organization (e.g. a law clinic or state legal aid)

Representative's Status Part B - Disqualification

I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice law.

Yes No

I am now or have previously been disqualified from participating in or appearing before a Federal program or agency.

Yes No
Form SSA-1696 (08-2020) UF Page 5 of 6
Claimant's Social Security Number Appointed Representative's Rep ID

4 3 0 - 6 9 - 8 7 9 8 5 R Z 7 Y Z 7 P F S

Section 5 - Continued (Representative Only)

Affiliation Information
If you are representing the claimant(s) as a partner or employee of a business entity, firm or other organization you may provide
your Employer Identification Number (EIN) here, if one exists for tax purposes. This number is not your Social Security Number
(SSN). This is your employer’s tax identification number. (Do not complete this section if you do not qualify for direct payment.)

EIN 8 6 - 2 3 5 5 1 3 6
Organization’s Name (Enter the full name of the business, entity, firm or organization with which you want to be affiliated while
representing this claim)
Trajector Disability
Representative's Business Address (if different than mailing address)
PO BOX 127
City State ZIP/Postal Code
LEHI UT 84043
Country - if outside the U.S.

Representative's Certifications

I accept this appointment and certify the following:

• I understand and agree that I will comply with SSA's laws and rules on the representation of parties, including the Rules of
Conduct and Standards of Responsibility for Representatives; I will not charge, collect, or retain a fee for representational
services that SSA has not approved or that is more than SSA approved unless a regulatory exclusion applies.
• I understand that if I fail to comply with any of SSA's laws and rules I may be suspended or disqualified as a representative
before SSA.
• I will not disclose any information to any unauthorized party without the claimant's specific written consent.
• I am not currently suspended or prohibited, for any reason, from practicing before the Social Security Administration.
• I am not disqualified from representing the claimant as a current or former officer or employee of the United States.
• I accept appointment as the representative for the claimant named in Section 2 of this form in connection with the claims and
asserted rights described in Section 6 of this form.
• I agree that a copy of this signed form SSA-1696 will have the same force and effect as the original.
• I declare under penalty of perjury that I have examined all of the information on this form and on all accompanying statements or
forms, including any information, attestations and certifications provided to SSA in registration, and that they are all currently true
and correct to the best of my knowledge.

If I intend to seek direct payment of the authorized fee on this claim -

• I have registered for and obtained a Rep ID, and my registration information is up-to-date.
• I have provided up-to-date information on my registration concerning whether I have been suspended or prohibited from practice
before SSA or any other Federal program or agency, disbarred or suspended by a court or bar, and convicted of a violation
under Section 206 or 1631(d) of the Social Security Act.

MJ
I CERTIFY TO ALL OF THE ABOVE (Representative's Initials)
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 SOCIAL SECURITY
FEE AGREEMENT

 This document allows our office to collect a fee for our work on
your claim, should you be approved for benefits.
 Generally, the fee for our work is 25% of your back benefits or
$7,200 - whichever is the smaller amount. This is a one-time fee
and will not come from your ongoing benefits. Normally, Social
Security withholds our fee and pays us directly.
 In the rare event that you are approved for benefits, but are
awarded little or no back pay, our office may petition Social
Security for a fee based on the work completed. This petition must
be approved by Social Security before any fee will be given to our
office.
 If you are not approved for benefits, there is no fee on your case.
We only ask to be reimbursed for any expenses we spent while
collecting your medical records.
o How much these medical records will cost is dependent by
state and what they allow for requesting medical records for
disability cases.
o You can gather your medical records on your own, should
you wish to do so. Some medical offices charge more when a
representative requests them than they would to the patient
gathering it themselves.
 SOCIAL SECURITY FEE AGREEMENT

Claimant: Biaca Bush SSN: 430-69-8798

I hereby hire TRAJECTOR DISABILITY, LLC (Merrick Jackson, Primary Representative) to represent
me in my claims for Social Security Disability and/or Supplemental Security Income (SSI) benefits before
the Social Security Administration (SSA). Merrick Jackson may designate other qualified individuals to
act as co-representative without prior notice. This agreement shall apply to all stages of the application
and appeals process within the Social Security Administration only, and not in Federal District Court.

If SSA favorably decides my claim(s) and the decision results in past-due (retroactive) benefits, I agree to
pay my representative(s) a fee that does not exceed the lesser of 25% of my past-due benefits or the
maximum dollar amount allowed under the Social Security Act Section 206(a)(2), which is currently
$7,200, or such higher amount set by the Commissioner of Social Security based on the date SSA
authorizes my representative's fee.

I understand that past-due benefits include any benefits payable to me, my eligible spouse, and any
affected auxiliary beneficiary.

I understand that I, my eligible spouse, and any affected auxiliary beneficiary, my representative or the
decision maker have the right to protest the fee authorized under this fee agreement, in writing, within 15
days from the authorization.

I understand that my representative(s) will only request a fee if I am awarded benefits. I also understand
that I may be approved for benefits without receiving any past-due (retroactive) benefits. If I have been
approved for disability but our fee agreement cannot be approved by SSA because there are no past-due
benefits, or for any other reason, I understand that my representative may file a fee petition to request that
SSA authorize a fee. I also understand that if there are no past-due benefits withheld, or if not enough past-
due benefits are withheld, I will be responsible to pay the authorized fee to my representative(s) directly.

I understand that any past-due benefits awarded are separate from out-of-pocket costs and expenses
related to my claim(s). I understand that SSA will not cover those costs, and I agree to reimburse my
representative(s) for costs incurred acquiring medical records, forms or narratives from my medical
treating sources, or special medical or vocational examinations.

I understand that the representative(s) reserves the right to withdraw from my case or that I may decide I
no longer want the representative(s) to represent me. In the event that I terminate this agreement, I
understand the representative(s) may nevertheless ask SSA to approve a fee for work performed on my
case. I understand that any fee my representative(s) receives must be approved by SSA.
{{#feeagrmtsig=SigFA_es_:signer1:signature}}

Jul 2, 2024
DATED (MONTH/DAY/YEAR), {{Dt_es_:signer1:date}}

ACCEPTED AND AGREED TO ON BEHALF OF:

Miss Biaca Nicole Bush

{{$feeagrmtsig}}
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)

Client Signature Merrick Jackson (Rep ID: 5RZ7YZ7PFS)

Primary Representative
TD#2621 (11-2022)
 SSA-8001:
APPLICATION FOR
SUPPLEMENTAL
SECURITY INCOME

 This document allows our office to apply for Supplemental

Security Income benefits, also known as SSI.
 This is a need-based benefit based on your household income and
assets (sometimes referred to as resources) as well as your
disabilities.
 Please read these pages carefully to make sure everything is
correct. We’ve included your information in the color blue. If there
are any mistakes, please call us at 1-800-652-9626 to let us know.
Form SSA-8001-BK (07-2023) UF
Discontinue Prior Editions Page 1 of 12
Social Security Administration OMB No. 0960-0444
Do Not Write in This Space
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
(Deferred or Abbreviated)

DEFERRED ABAP
SNAP- SNAP-
SSA/APP REFERRED
I am/We are applying for Supplemental Security Income and any federally Filing Date (MM/DD/YYYY)
administered state supplementation under Title XVI of the Social Security
Act, for benefits under the other programs administered by the Social Receipt Protective
Security Administration, and where applicable, for medical assistance under Preferred Language:
Title XIX of the Social Security Act.
Written:
English
Spoken: English

Individual with Child with

TYPE OF CLAIM Individual Couple Child
Ineligible Spouse Parent(s)

PART 1 - BASIC ELIGIBILITY - Answer the questions below beginning with the first moment of the filing date month.

1(a) First Name, Middle Initial, Last Name (b) Birthdate (c) Social Security Number
(MM/DD/YYYY)
Biaca Nicole Bush 11/22/1974 430-69-8798
2(a) If filing as spouse or couple Spouse's Name(s) (b) Birthdate (c) Social Security Number(s)
(MM/DD/YYYY)

3(a) If filing for child Parent 1's Name(s) (b) Birthdate (c) Social Security Number(s)
(MM/DD/YYYY)

(d) If filing for child Parent 2's Name(s) (e) Birthdate (f) Social Security Number(s)
(MM/DD/YYYY)

4(a) Are you married? (b) Date of Marriage

(MM/DD/YYYY)
YES NO, Go to #5.
(c). Are you and your spouse living together?
YES NO If no, date you began living apart

5(a) Are you and another person living together in the same household and presenting to others or the community as a
married couple?

YES, provide the date holding out began (MM/DD/YYYY) . Go to (b).

NO Go to #6.

*(b) Other person's name (First, middle initial, last) (c) Other person's Social
Security Number

*Use SSA-4178 to develop the holding out relationship.

Form SSA-8001-BK (07-2023) UF Page 2 of 12
6. Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d).
(a) Your Other Name(s) (including Name at Birth) Social Security Number
Biaca Stewart
(b) Spouse's Other Name(s) (including Name at Birth) Social Security Number

(c) Parent 1's Other Name(s) (including Name at Birth) Social Security Number

(d) Parent 2's Other Name(s) (including Name at Birth) Social Security Number

7. Your Place of Birth (City and State or Foreign Country)

Little Rock, AR
8. Spouse's Place of Birth (City and State or Foreign Country)

9. If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
You Your Spouse, if filing

(a) Are you unable to work or is your work limited YES NO YES NO
because of illnesses, injuries, or conditions?
Go to (b) Go to #10 Go to (b) Go to #10
(MM/DD/YYYY) (MM/DD/YYYY)
(b) Enter the date you became unable to work
02/28/2024
Go to (c) Go to (c)

(c) Are you blind or do you have low vision even with YES NO YES NO
glasses or contacts?
Go to (d) Go to (d)

(d) If you were unable to work because of illnesses, injuries, or YES NO

conditions before age 22, do you have a parent or stepparent Provide name(s) and Social Go to #10
who is age 62 or older, unable to work because of illnesses, Security Number(s) in Remarks
injuries, or conditions, or deceased? Go to #10

(e) When did the child become disabled? (MM/DD/YYYY) Go to (f)

(f) Is the child blind or does he or she have low vision even with YES NO
glasses or contacts? Go to (g) Go to (g)

YES NO
(g) Does the child have a parent or stepparent who is 62 or older,
unable to work because of illnesses, injuries, or conditions, or Provide name(s) and Social Go to #10
deceased? Security Number(s) in Remarks
Go to #10
10. If you (and your spouse filing for benefits) were a United States citizen at birth, go to #14; otherwise go to (a).
You Your Spouse, if filing

(a) Are you a naturalized United States citizen? YES NO YES NO

Go to #14 Go to (b) Go to #14 Go to (b)

(b) Are you an American Indian born outside the YES NO YES NO
United States? Go to (c) Go to (d) Go to (c) Go to (d)
Form SSA-8001-BK (07-2023) UF Page 3 of 12
10. (c) Check the block that shows your American Indian status.

You Your Spouse, if filing

American Indian born in Canada Go to #14 American Indian born in Canada Go to #14
Member of a Federally recognized Indian Tribe; Member of a Federally recognized Indian Tribe;

Name of Tribe: Go to #14 Name of Tribe: Go to #14

Other American Indian Other American Indian

Explain in Remarks, then Go to (d) Explain in Remarks, then Go to (d)

(d) Check the block below that shows your current immigration status.

You Your Spouse, if filing

Amerasian Immigrant Amerasian Immigrant

Go to #11 Go to #11
Asylee Asylee
Date status granted (MM/DD/YYYY): Date status granted (MM/DD/YYYY):
Go to #13 Go to #13
Conditional Entrant Conditional Entrant
Date status granted (MM/DD/YYYY): Date status granted (MM/DD/YYYY):
Go to #13 Go to #13
Cuban/Haitian Entrant Cuban/Haitian Entrant
Go to #13 Go to #13
Deportation/Removal Withheld Deportation/Removal Withheld
Date (MM/DD/YYYY): Date (MM/DD/YYYY):
Go to #13 Go to #13
Lawful Permanent Resident Lawful Permanent Resident
Go to #11 Go to #11
Parolee for One Year Parolee for One Year
Go to #13 Go to #13
Refugee Refugee
Date of entry (MM/DD/YYYY): Date of entry (MM/DD/YYYY):
Go to #13 Go to #13
Unknown/Other Unknown/Other

Explain in Remarks, then Go to (e) Explain in Remarks, then Go to (e)

(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United States citizen, or a
lawfully admitted permanent resident, Go to #12; otherwise, Go to #14.
Form SSA-8001-BK (07-2023) UF Page 4 of 12
You Your Spouse, if filing
(MM/DD/YYYY) (MM/DD/YYYY)
11(a) Date of admission:

(b) Was your entry into the United States sponsored

YES NO YES NO
by any person or promoted by an institution or
group? Go to (c) Go to (d) Go to (c) Go to (d)

(c) Give the following information about the person, institution or group:
Name Address Phone Number

You Your Spouse, if filing

(MM/DD/YYYY) (MM/DD/YYYY)
(d) What was your immigration status, if any, before From: From:
adjustment to lawful permanent resident?
To: To:

(e) If filing as an adult, did your parents ever work in YES NO YES NO
the United States before you were 18? Go to (f) Go to #13 Go to (f) Go to #13

(f) Name and Social Security Number of parent(s) who worked.

Name Social Security Number

Name Social Security Number

You Your Spouse, if filing

12(a) Have you, your child, or your parent, been

YES NO YES NO
subjected to battery or extreme cruelty while in
the United States? Go to (b) Go to #14 Go to (b) Go to #14

(b) Have you, your child, or your parent filed a

petition with the Department of Homeland
YES NO YES NO
Security for a change in immigration status
because of being subjected to battery or extreme Go to #14 Go to #14 Go to #14 Go to #14
cruelty?

YES NO YES NO
13. Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the Explain in Go to #14 Explain in Go to #14
United States? Remarks, then Remarks, then
Go to #14 Go to #14
(MM/DD/YYYY) (MM/DD/YYYY)
14(a) When did you first make your home in the United
States? 11/22/1974

(b) Have you lived outside of the United States since YES NO YES NO
then? Go to (c) Go to #15 Go to (c) Go to #15
(MM/DD/YYYY) (MM/DD/YYYY)
Date Date
(c) Give the date(s) of residence outside the United Left: Left:
States. (MM/DD/YYYY) (MM/DD/YYYY)
Date Date
Returned: Returned:
Form SSA-8001-BK (07-2023) UF Page 5 of 12
You Your Spouse, if filing

15(a) Have you been outside the United States (the 50

YES NO YES NO
States, District of Columbia and Northern
Mariana Islands) 30 days prior to the filing date? Go to (b) Go to #16 Go to (b) Go to #16

(MM/DD/YYYY) (MM/DD/YYYY)
Date Date
(b) Give the date (MM/DD/YYYY) you left the United
Left: Left:
States and the date you returned to the United
States. (MM/DD/YYYY) (MM/DD/YYYY)
Date Date
Returned: Returned:
16. Claimant's Mailing Address (Number & Street, Apt. No., P.O. Box, or Rural Route)

2124 Labette Manor Dr Apt L14

City and State (U.S.) ZIP Code Name of County in which you live Telephone Number
Little Rock, AR 72205 501-940-4324
State/Province/Region (Foreign) Postal Code Country

You Your Spouse, if filing

17(a) Do you have any felony warrants for escape from
custody, flight to avoid prosecution or YES NO YES NO
confinement, or flight escape? Go to (b) Go to #18 Go to (b) Go to #18
Name of State/Country Name of State/Country
(b) In which State or country was the warrant issued?
Go to (c) Go to (c)
YES NO YES NO
(c) Was the warrant satisfied?
Go to (d) Go to #18 Go to (d) Go to #18
(MM/DD/YYYY) (MM/DD/YYYY)
(d) Date warrant satisfied:

PART 2 - LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first moment of the filing date
month and today.)
18. Claimant's Residence Address (Number & Street, Apt. No., P.O. Box, or Rural Route)

2124 Labette Manor Dr Apt L14

City and State (U.S.) ZIP Code Name of County in which you live
Little Rock, AR 72205
State/Province/Region (Foreign) Postal Code Country

19(a) Mark the box that describes where you live.

Noninstitution (rest home, retirement home, foster home, or
House, apartment, mobile home, houseboat group home)
Room in commercial establishment Institution (hospital, rehabilitation center, prison, or school)
Room in private home Transient or homeless

(b) Date you began living there: (MM/DD/YYYY) 02/28/2024

20. Mark the box that describes with whom you live. If you live in a foster home, group home, or an institution, or if you are a
transient or homeless, do not answer but explain in remarks.
Alone Spouse/Parents and/or Children Other People
Form SSA-8001-BK (07-2023) UF Page 6 of 12
PART 3 - RESOURCES (Show resources as of the first moment of the filing date month. Use "Remarks" to explain any
changes.)
21. If you own, or your name or your spouse's/parent's name(s) appear on any of the following items (either alone or with other
people's name(s)), enter the total cash value of item(s) on each line.
Co-owned Dollar Value
Description of Items Dollar Value
Yes No With Others Spouse or
Marked Yes You Own
Yes No Parents Own

(a) Trust. $ 0 $ 0

(b) Vehicle. 0 $ 0 $

(c) Real Property Other Than

$ 0 $ 0
Home.

(d) Business Equipment. $ 0 $0

(e) Achieving a Better Life

$ 0 $0
Experience (ABLE) Account.
Chime
(f) Financial Institution Account. $ 0.17 $ 0

(g) Cash. $0 $ 0

(h) Stock, Bond or Mutual Fund. $0 $ 0

(i) Promissory Note, Loan, or

$0 $ 0
Property Agreement.
(j) Items Held for Potential Value 0
$ 0 $
or Investment.

(k) Life Insurance. $ 0 $ 0

(l) Burial Fund. $ 0 $ 0

(m) Burial Space or Related Item. $ 0 $ 0

(n) Other Resource. $ 0 $ 0

Your answer YES NO

22. Are there any assets set aside to meet burial Spouse's answer YES NO
expenses for you or your spouse/parent(s)? (If"Yes"
describe the item in "Remarks". Parent 1's answer YES NO
Parent 2's answer YES NO
Form SSA-8001-BK (07-2023) UF Page 7 of 12
You Your Spouse, if filing
23(a) Have you or your spouse sold, transferred title,
disposed of or given away, any money or other
property, including money or property in foreign YES NO YES NO
countries, since the first moment of the filing date
month or within the 36 months prior to filing date
month?
b) If you co-owned any money or property with
another person(s), did you or any co-owner sell,
transfer, or give away any co-owned money or YES NO YES NO
property within the 36 months prior to the filing
date month?

IF YOU ANSWERED "YES" TO (a) or (b), GO TO (c). IF "NO" TO BOTH, GO TO #24.

(c) Owner's/Co-Owner's Name Description of Property Date of Disposal

Item #1

Item #2

Item #3

Name and Address of Purchaser or Value of Property and/

Relationship to Owner
Recipient or Amount of Cash Gift

Item #1 $

Item #2 $

Item #3 $

Are Other Considerations or Proceeds Do You Still Own Part

Sale Price or Other Consideration
Expected? Explain of the Property?

Item #1 YES NO

Item #2 YES NO

Item #3 YES NO

Traded for Goods/

Sold on Open Market? Given Away?
Services?
Item #1 YES NO YES NO YES NO
Item #2 YES NO YES NO YES NO
Item #3 YES NO YES NO YES NO
You Your Spouse, if filing
24. Do you give us permission to obtain any financial
records from any financial institution? YES NO YES NO
Form SSA-8001-BK (07-2023) UF Page 8 of 12
PART 4 - INCOME (List all income received since the first moment of the filing date month or expected in the next 3
months.) Include you, your spouse/parents.
25. List cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect to receive. Include
income from wages, sick pay, self-employment, interest, social security, assistance based on need, VA, gifts, pensions, and
any other type of income. Give date last paid if income will stop in the next 3 months.
Frequency
Person Receiving Income Type of Income Amount Date Last Paid Source of Income
Received

Parent Pays Bills $ Juanice Bush

Also, note here if anyone pays any bills for you directly or gives you money to pay them.
YES NO
26(a) Does your spouse/parent pay court ordered child support?
Go to (b) Go to #27
(b) Give the amount and frequency of payment:
$
PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/
MEDICAL ASSISTANCE
You Your Spouse, if filing
27(a) Are you currently receiving SNAP benefits YES NO YES NO
(formerly food stamps)? Go to (b) Go to (c) Go to (b) Go to (c)
(b) Have you received a recertification notice within YES NO YES NO
the past 30 days? Go to (e) Go to #28 Go to (e) Go to #28

(c) Have you filed for SNAP benefits in the last 60 YES NO YES NO
days? Go to (d) Go to (e) Go to (d) Go to (e)

(d) Have you received a favorable decision? YES NO YES NO

Go to #28 Go to (e) Go to #28 Go to (e)

(e) May I take your SNAP application today? YES NO YES NO

Go to #28 Explain in (f) Go to #28 Explain in (f)
(f) Explanation:

28. You may be eligible for Medicaid. However, you must help your State identify other sources that pay for medical care. Also,
you must give information to help the State get medical support for any child(ren) who is your legal responsibility. This
includes information to help the State determine who a child's parent is. If you want Medicaid, you must agree to allow your
State to seek payments from sources, such as insurance companies, that are available to pay for your medical care. This
includes payments for medical care for you or any person who receives Medicaid and is your legal responsibility. The State
cannot provide you Medicaid if you do not agree to this Medicaid requirement. If you need further information, you may
contact your Medicaid Agency.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to (b)
You Your Spouse, if filing
(a) Do you agree to assign your rights (or the
rights of anyone for whom you can legally YES NO YES NO
assign rights) to payments for medical
support and other medical care to the State Go to (b) Go to #29 Go to (b) Go to #29
Medicaid agency?
Form SSA-8001-BK (07-2023) UF Page 9 of 12
You Your Spouse, if filing
28(b) Do you, your spouse, parent or stepparent have
any private, group, or governmental health YES NO YES NO
insurance that pays the cost of your medical Go to (c) Go to (c) Go to (c) Go to (c)
care? (Do not include Medicare or Medicaid.)
(c) Do you have any unpaid medical expenses for YES NO YES NO
the 3 months prior to the filing date month? Go to #29 Go to #29 Go to #29 Go to #29

PART 6 - MISCELLANEOUS

ANSWER #29(a) ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE;
OTHERWISE GO TO #29(b).
29(a) Name of Person Requesting Benefits Relationship to Claimant Your Social Security Number

(b) Have you ever served as representative payee for a Social

YES NO
Security beneficiary or SSI claimant?

PART 7 - REMARKS - (You may use this space for any explanations. Enter the item number before each explanation. If
you need more space, use a signed form SSA-795.)
Form SSA-8001-BK (07-2023) UF Page 10 of 12
PART 8 - IMPORTANT INFORMATION - PLEASE READ CAREFULLY

The Social Security Administration will check your statements and compare its records with records from other state and Federal
agencies, including the Internal Revenue Service, to make sure you are paid the correct amount. We have asked you for
permission to obtain, from any financial institution, any financial record about you that is held by the institution. We will ask
financial institutions for this information whenever we think it is needed to decide if you are eligible or if you continue to be eligible
for SSI benefits. Once authorized, our permission to contact financial institutions remains in effect until one of the following
occurs: (1) you or your spouse notify us in writing that you are canceling your permission, (2) your application for SSI is denied in
a final decision, (3) your eligibility for SSI terminates, or (4) we no longer consider your spouse's income and resources to be
available to you. If you or your spouse do not give or cancel your permission you may not be eligible for SSI and we may deny
your claim or stop your payments.

PART 9 - SIGNATURES

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 statement
about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or
imprisonment.
Your Signature (First name, middle initial, last name) (Write in ink.) Date (MM/DD/YYYY)

{{Sig_es_:signer1:signature}}
Miss Biaca Nicole Bush
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)
{{D_es_:signer1:date}}
Jul 2, 2024
Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)

If you are blind or visually impaired, check the type of mail you want to receive from us

Standard notice First-Class Standard notice First-Class with a follow-up phone call
Standard notice & data CD by First-Class Standard notice Certified
Standard & Braille notices by First-Class Standard & large print notices
Standard notice & audio CD

WITNESSES

Your application does not ordinarily have to be witnessed. If, however, you have signed by mark (X), two witnesses to the signing,
who know you, must sign below giving their full address.

1. Signature of Witness 2. Signature of Witness

Address (Number and Street, City, State, and ZIP Code) Address (Number and Street, City, State, and ZIP Code)

Biaca Bush 8798

Form SSA-8001-BK (07-2023) UF Page 11 of 12
RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOME

Name Social Security Number Date

Biaca Bush 430-69-8798
Name Social Security Number Date

If you have a question or something to report call: Social Security Office you may visit or write to:

Your application for Supplemental Security Income will be processed as quickly as possible. You should hear from us within
days. If you do not hear from us within that time, please get in touch with us in person, by mail, or call us at the telephone number
shown at the top of this page.

We may need more information before we can decide whether or not you are eligible for SSI payments. If we need more
information, we will contact you. In the meantime, if you move or change your mailing address, you (or someone for you) should
report the change to the office shown at the top of this page.

You (or someone for you) must let us know if your immigration status changes.

Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. You could lose some
SSI payments if you do not let us know right away.

Always give your Social Security Number when writing or telephoning about your claim. If you have any questions about your
claim, we will be glad to help you.
Form SSA-8001-BK (07-2023) UF Page 12 of 12

Privacy Act Statement

Collection and Use of Personal Information

Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any
claim filed.

We will use the information to determine eligibility for Supplemental Security Income (SSI) payments. We may also
share your information for the following purposes, called routine uses:

• To specified business and other community members and Federal, State, and local agencies for verification of
eligibility for benefits under section 1631(e) of the Act; and

• To State agencies to enable them to assist in the effective and efficient administration of the SSI program.

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) 60-0089, entitled
Claims Folders Systems, as published in the Federal Register (FR) on April 01, 2003, at 68FR 15784, and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11,
2006, at 71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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 19-20 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.
 SSA-16:
APPLICATION FOR DISABILITY
INSURANCE BENEFITS

 This document allows our office to apply for Social Security

Disability Insurance benefits.
 This benefit is based off of the work you have done in the past 10
years and the amount of Social Security (FICA) taxes paid at those
jobs.
 Please read these pages carefully to make sure everything is
correct. We’ve included your information in the color blue. If there
are any mistakes, please call us at 1-800-652-9626 to let us know.
Form SSA-16 (06-2022) UF
Discontinue prior editions Page 1 of 7
Social Security Administration OMB No. 0960-0618
(Do not write in this space)
APPLICATION FOR DISABILITY INSURANCE BENEFITS
I apply for a period of disability and/or all insurance benefits for which I am
eligible under Title II and Part A of Title XVIII of the Social Security Act, as
presently amended.
1. PRINT your name FIRST NAME, MIDDLE INITIAL, LAST NAME

Biaca Nicole Bush

2. Enter your Social Security Number
430-69-8798
3. Check (X) whether you are Female Male

Answer question 4 if English is not your preferred language. Otherwise, go to item 5.

4. Enter the language you prefer to: speak English write English
5. (a) Enter your date of birth
11/22/1974
(b) Enter name of city and state or foreign country where you
Little Rock, AR
were born.
6. Yes No
(a) Are you a U.S. citizen? (If "No," answer (b))
(If "Yes," go to item 7)
Yes No
(b) Are you an alien lawfully present in the U.S.?
(If "Yes," answer (c)) (If "No," go to item 7)
(c) When were you lawfully admitted to the U.S.?
7.
(a) Enter your name at birth if different from item (1)

(b) Have you used any other names? Yes No

(If "Yes," answer (c)) (If "No," go to item 8)

(c) Other name(s) used. Biaca Stewart

8. Yes No
(a) Have you used any other Social Security number(s)?
(If "Yes," answer (b)) (If "No" go to item 9)

(b) Enter Social Security number(s) used.

9. When do you believe your condition(s) became severe enough to

keep you from working (even if you have never worked)? 02/28/2024
10. Did you or your spouse (or prior spouse) work in the railroad
Yes No
industry for 5 years or more?
11. (a) Do you have Social Security credits (for example, based on work Yes No
or residence) under another country's Social Security System? (If "Yes," answer (b)) (If "No," go to item 12)
(b) List the country(ies):
12. (a) Are you entitled to, or do you expect to be entitled to, a pension Yes No
or annuity (or a lump sum in place of a pension or annuity) based (If "No," go to item 13)
on your work after 1956 not covered by Social Security? (If "Yes," answer
(b) and (c))
(b) I became entitled, or expect to become entitled, beginning MONTH YEAR

(c) I became eligible, or expect to become eligible, beginning MONTH YEAR

I AGREE TO PROMPTLY NOTIFY the Social Security Administration if I become entitled to a pension or annuity
based on my employment not covered by Social Security, or if such pension or annuity stops.
Form SSA-16 (06-2022) UF Page 2 of 7

13. Yes No
(a) Have you ever been married?
(If "Yes," answer (b)) (If "No," go to item 14)
(b) Give the following information about your current marriage. If not currently married,
write "None." (If "None," go on to item 13(c))
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

Marriage performed by: Spouse's date of birth (or age) Spouse's Social Security Number
(If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
(c) Enter information about any other marriage if you:
• Had a marriage that lasted at least 10 years; or
• Had a marriage that ended due to the death of your spouse, regardless of duration; or
• Were divorced, remarried the same individual within the year immediately following the year of the divorce, and
the combined period of marriage totaled 10 years or more. If none, write "None." Go on to item 13
(d) if you have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began
before age 22) and you are divorced from the child's other parent who is now deceased and the marriage lasted
less than 10 years.
Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

How marriage ended When (Month, day, year) Where (Name of City and State)

Marriage performed by: Spouse's date of Date of spouse's death Spouse's Social Security Number
birth (or age) (If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)
(d) Enter information about any marriage if you:

• Have a child(ren) who is under age 16 or disabled or handicapped (age 16 or over and disability began before
age 22); and
• Were married for less than 10 years to the child's mother or father, who is now deceased; and
• The marriage ended in divorce
If none, write "None."

Spouse's name (including maiden name) When (Month, day, year) Where (Name of City and State)

Date of divorce (Month, day, year) Where (Name of City and State)

Marriage performed by: Spouse's date of birth Date of spouse's death Spouse's Social Security Number
(or age) (If none or unknown, so indicate)
Clergyman or public official
Other (Explain in Remarks)

Use the "REMARKS" space on page 5 for marriage continuation or explanation.

14. If your claim for disability benefits is approved, your children (including adopted children, and stepchildren) or
dependent grandchildren (including stepgrandchildren) may be eligible for benefits based on your earnings record.

List below: FULL NAME OF ALL such children who are now or were in the past 12 months UNMARRIED and:
• UNDER AGE 18
• AGE 18 TO 19 AND ATTENDING ELEMENTARY OR SECONDARY SCHOOL FULL-TIME
• DISABLED OR HANDICAPPED (age 18 or over and disability began before age 22)
Form SSA-16 (06-2022) UF Page 3 of 7
15. (a) Did you have wages or self-employment income covered under Yes No
Social Security in all years from 1978 through last year? (If "Yes," go to item 16) (If "No," answer (b))
(b) List the years from 1978 through last year in which you did not
have wages or self-employment income covered under
Social Security.
16. Enter below the names and addresses of all the persons, companies, or Government agencies for whom you have
worked this year and last year. IF NONE, WRITE "NONE" BELOW AND GO TO ITEM 17.

Work Ended (If still

NAME AND ADDRESS OF EMPLOYER
Work Began working show
(If you had more than one employer, please list them
"Not Ended")
in order beginning with your last (most recent) employer)
MONTH YEAR MONTH YEAR

Indotroix International Corporation, Rochester NY, 08/2023 02/2024

(If you need more space, use "Remarks".)

17. Complete item 17 even if you were an employee.

(a) Were you self-employed this year or last year? Yes No

(If "Yes," answer (b)) (If "No," go to item 18)
(b) Check the year (or In what type of trade/business Were your net earnings from the
years) you were were you self-employed? trade or business $400 or more?
self-employed (For example, storekeeper, farmer, (Check "Yes" or "No")
physician)
This year
Last year Yes No
18. (a) How much were your total earnings last year?
Count both wage and self-employment income. Amount $ 6000.00
(If none, write "None.")
(b) How much have you earned so far this year?
(If none, write "None.") 2000.00
Amount $
19. (a) Are you still unable to work because of your illnesses, injuries, Yes No
or conditions? (If "Yes," go to item 20) (If "No," answer (b))
MONTH, DAY, YEAR
(b) Enter the date you became able to work.

20. Are your illnesses, injuries, or conditions related to your work in

Yes No
any way?
21. Are you blind or do you have low vision even with glasses or
Yes No
contacts?
Form SSA-16 (06-2022) UF Page 4 of 7
22. (a) Have you filed, or do you intend to file, for any other public Yes No
disability benefits (including workers' compensation, Black Lung
(If "Yes," answer (b)) (If "No," to item 23)
benefits and SSI)?
(b) The other public disability benefit(s) you have filed (or intend to file) for is (Check as many as apply):

Veterans Administration Benefits Welfare

Supplemental Security Income Other (If "Other," complete a Workers' Compensation/Public

Disability Benefit Questionnaire)
23. (a) Did you receive any money from an employer(s) on or after the
Yes No
date in item 9 when you became unable to work because of your
illnesses, injuries, or conditions? If "Yes", give the amounts and
explain in "Remarks". Amount $ 0
(b) Do you expect to receive any additional money from an
Yes No
employer, such as sick pay, vacation pay, other special pay? If
"Yes," please give amounts and explain in "Remarks".
Amount $ 0
24. Do you, or did you, have a child under age 3 (your own or your
spouse's) living with you in one or more calendar years when you Yes No
had no earnings?
25. Do you have a dependent parent who was receiving at least one-
half support from you when you became unable to work because of
Yes No
your disability? If "Yes," enter the parent's name and address and
Social Security number, if known, in "Remarks".
26. If you were unable to work before age 22 because of an illness,
injury or condition, do you have a parent (including adoptive or
stepparent) or grandparent who is receiving social security
retirement or disability benefits or who is deceased? If yes, enter the Yes No Unknown
name(s) and Social Security number, if known, in "Remarks" (if
unknown, check "Unknown").
Form SSA-16 (06-2022) UF Page 5 of 7
REMARKS (You may use this space for any explanation. If you need more space, attach a separate sheet.)

Biaca Bush 8798

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 statement about a material fact in this information, or causes someone else to do so, commits a crime and may be
subject to a fine or imprisonment.
Date (Month, Day, Year)
SIGNATURE OF APPLICANT
{{Dt_es_:signer1:date}}
Jul 2, 2024
Signature (First name, middle initial, last name) (Write in ink) Telephone Number(s) at which you
may be contacted during the day.
{{S_es_:signer1:signature}}
Miss Biaca Nicole Bush
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)
(Include the area code)
501-940-4324
DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)
Routing Transit Number Account Number Checking Enroll in Direct Express
Savings Direct Deposit Refused
Applicant's Mailing Address (Number and street, Apt No., P.O. Box, or Rural Route) (Enter Residence Address in
"Remarks," if different.)

2124 Labette Manor Dr Apt L14

City and State ZIP Code County (if any) in which you now live
Little Rock, AR 72205
Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses. Also, print the applicant's
name in Signature block.
1. Signature of Witness 2. Signature of Witness

Address (Number and street, City, State and ZIP Code) Address (Number and street, City, State and ZIP Code)
Form SSA-16 (06-2022) UF Page 6 of 7
FOR YOUR INFORMATION

An agency in your State that works with us in administering the Social Security disability program is
responsible for making the disability decision on your claim. In some cases, it is necessary for them to get
additional information about your condition or to arrange for you to have a medical examination at
Government expense.

Privacy Act Statement

Collection and Use of Information

Sections 202, 205, 223(a), and 226 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an
accurate and timely decision on the claim for benefits.

We will use the information you provide to establish or determine benefits eligibility. We may also share the
information for the following purposes, called routine uses:

·To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient
administration of our programs; and

·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
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, as published in the Federal Register (FR) on January
11, 2006, at 71 FR 1819 and 60-0089, entitled Claims Folders System, as published in the FR on October 31, 2019,
at 84 FR 58422. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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 20 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.
Form SSA-16 (06-2022) UF Page 7 of 7
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY DISABILITY INSURANCE BENEFITS
Person to Contact About Your Claim SSA OFFICE Date Claim Received

Telephone Number (Include Area Code)

Your application for Social Security disability benefits has is some other change that may affect your claim, you - or
been received and will be processed as quickly someone for you - should report the change. The changes
as possible. to be reported are listed below.

You should hear from us within days after you Always give us your claim number when writing or
have given us all the information we requested. Some telephoning about your claim.
claims may take longer if additional information is needed.
If you have any questions about your claim, we will be glad
In the meantime, if you change your address, or if there to help you.
CLAIMANT SOCIAL SECURITY CLAIM NUMBER
Biaca Bush 430-69-8798
CHANGES TO BE REPORTED AND HOW TO REPORT
FAILURE TO REPORT MAY RESULT IN OVERPAYMENTS THAT MUST BE REPAID
• You change your mailing address for checks or crime that is a felony of flight to avoid prosecution or
residence. To avoid delay in receipt of checks you confinement, escape from custody and flight-escape. In
should ALSO file a regular change of address notice with most jurisdictions that do not classify crimes as felonies,
your post office. this applies to a crime that is punishable by death or
imprisonment for a term exceeding one year (regardless
• Your citizenship or immigration status changes. of the actual sentence imposed).

• You go outside the U.S.A. for 30 consecutive days or • You have an unsatisfied warrant for more than 30
longer. continuous days for a violation of probation or parole
under Federal or State law.
• Any beneficiary dies or becomes unable to
handle benefits. • Change of Marital Status - Marriage, divorce, annulment
of marriage.
• Custody Change - Report if a person for whom you are
filing or who is in your care dies, leaves your care or • If you become the parent of a child (including an adopted
custody, or changes address. child) after you have filed your claim, let us know about
the child so we can decide if the child is eligible for
• You are confined to a jail, prison, penal institution or benefits. Failure to report the existence of these children
correctional facility for more than 30 continuous days for may result in the loss of possible benefits to
conviction of a crime, or you are confined for more than the child(ren).
30 continuous days to a public institution by a court order
in connection with a crime. • You return to work (as an employee or self-employed)
regardless of amount of earnings.
• You become entitled to a pension, an annuity, or a lump
sum payment based on your employment not covered by • Your condition improves.
Social Security, or if such pension or annuity stops.
• You are under full retirement and you apply for or begin to
• Your stepchild is entitled to benefits on your record and receive workers' compensation (including black lung
you and the stepchild's parent divorce. Stepchild benefits benefits) or another public disability benefit, or the
are not payable beginning with the month after the month amount of your present workers' compensation or public
the divorce becomes final. disability benefit changes or stops, or you receive a
lump-sum settlement.
• You have an unsatisfied warrant for more than 30
continuous days for your arrest for a crime or attempted
HOW TO REPORT
You can make your reports online, by telephone, mail, or in person, whichever you prefer. If you are awarded benefits, and
one or more of the above change(s) occur, you should report by:
• Visiting the section "my Social Security" at our web site at www.socialsecurity.gov;
• Calling us TOLL FREE at 1-800-772-1213;
• If you are deaf or hearing impaired, calling us TOLL FREE at TTY 1-800-325-0778; or
• Calling, visiting or writing your local Social Security office at the phone number and address shown on your
claim receipt.

For general information about Social Security, visit our web site at www.socialsecurity.gov.
 SSA-827:
AUTHORIZATION TO
DISCLOSE INFORMATION

 This document allows Social Security to request medical records

and other disability related information during the process of your
claim.
Form SSA-827 (03-2020) Page 1 of 2
Discontinue Prior Editions OMB No. 0960-0623
Whose Records to be Disclosed
{{#sig=S_es_:signer1:signature}} NAME (First, Middle, Last, Suffix)
Biaca Nicole Bush
{{#date=D_es_:signer1:date}} SSN Birthday (MM/DD/YYYY)
430-69-8798 11/22/1974
AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION (SSA)
** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW **
I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):
OF WHAT All my medical records: also education records and other information related to my ability to perform tasks. This includes Specific
permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, and not
limited to:
• Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501)
• Drug abuse, alcoholism, or other substance abuse
• Sickle cell anemia
• Records which may indicate the presence of a communicable or noncommunicable disease; and tests for or records of HIV/AIDS
• Gene-related impairments (including genetic test results)
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and speech
evaluations, and any other records that can help evaluate function; also teachers' observations and evaluations.
4. Information created within 12 months after the date this authorization is signed, as well as past information.
FROM WHOM
• All medical sources (hospitals, clinics, labs,
THIS BOX TO BE COMPLETED BY SSA/DDS (as needed). Additional information to identify the
physicians, psychologists, etc.) including mental
subject (e.g., other names used), the specific source, or the material to be disclosed:
health, correctional, addiction treatment, and VA
health care facilities
• All educational sources (schools, teachers, records
administrators, counselors, etc.)
• Social workers/rehabilitation counselors
• Consulting examiners used by SSA
• Employers, insurance companies, workers'
compensation programs
• Others who may know about my condition (family,
neighbors, friends, public officials)
TO WHOM The Social Security Administration and to the State agency authorized to process my case (usually called "disability determination
services"), including contract copy services, and doctors or other professionals consulted during the process. [Also, for international
claims, to the U.S. Department of State Foreign Service Post.]
PURPOSE Determining my eligibility for benefits, including looking at the combined effect of any impairments that by themselves would not meet SSA's
definition of disability; and whether I can manage such benefits.
Determining whether I am capable of managing benefits ONLY (check only if this applies)
EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
• I understand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details).
• I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details).
• SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.
• I have read both pages of this form and agree to the disclosures above from the types of sources listed.
PLEASE SIGN USING BLUE OR BLACK INK ONLY IF not signed by subject of disclosure, specify basis for authority to sign
INDIVIDUAL authorizing disclosure Signature Parent of minor Guardian Other personal representative
(explain)
Miss Biaca Nicole Bush
{{$sig
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)
}} (Parent/guardian/personal representative sign
here if two signatures required by State law)
Signed
Date S d Street Address
Jul 2, 2024
{{$date }} 2124 Labette Manor Dr Apt L14
Phone Number (with area code) City State ZIP
501-940-4324 Little Rock AR 72205
WITNESS I know the person signing this form or am satisfied of this person's identity:
Signature IF needed, second witness sign here (e.g., if signed with "X" above)

Phone Number (or Address) Phone Number (or Address)

800-652-9626

This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and other
information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section 7332; 38 CFR 1.475;
20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law.
Form SSA-827 (03-2020) Page 2 of 2
Explanation of Form SSA-827,
"Authorization to Disclose Information to the Social Security Administration (SSA)"
We need your written authorization to help get the information required to process your claim, and to determine your capability of
managing benefits. Laws and regulations require that sources of personal information have a signed authorization before
releasing it to us. Also, laws require specific authorization for the release of information about certain conditions and from
educational sources.

You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to release
that information if you sign a single authorization to release all your information from all your possible sources. We will make
copies of it for each source. A covered entity (that is, a source of medical information about you) may not condition treatment,
payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and some individual
sources of information, require that the authorization specifically name the source that you authorize to release personal
information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need
you to sign more authorizations.

You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to
take an action. To revoke, send a written statement to any Social Security Office. If you do, also send a copy directly to any of
your sources that you no longer wish to disclose information about you; SSA can tell you if we identified any sources you didn't tell
us about. SSA may use information disclosed prior to revocation to decide your claim.

It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act. SSA
makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred
language.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(d) 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 on your claim that could result in a denial or loss of benefits.

We will use the information you provide to determine your eligibility or continuing eligibility for benefits, and your ability to manage
any benefits that you currently receive.

We may also share your information for the following purposes, called routine uses:

1. To State audit agencies for auditing State supplementation payments and Medicaid eligibility considerations;
2. To third party contacts where necessary to establish or verify information provided by representative payees or payee
applicants; and
3. To Federal, State or local agencies for administering cash or non-cash income maintenance or health maintenance
programs.

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 (SORNs) 60-0089, entitled Claims
Folders Systems; 60-0090, entitled Master Beneficiary Record; 60-0320, entitled Electronic Disability; and 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.
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 10 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.
 INFORMATION ON
MEDICARE, MEDICAID, AND
MEDICARE ADVANTAGE
OPTIONS

 Should you be awarded disability benefits, this form allows our

affiliated companies, Myler Insurance and Trajector Insurance, to
contact you to discuss your insurance options and to potentially
assist you in locating insurance.
 Information on Medicare, Medicaid,
and Medicare Advantage Options

If you are successful in getting Social Security Disability or SSI benefits, you will probably also
be eligible for Medicare or Medicaid. Trajector Disability is partnered with a business called
Insurance Branch, which helps in assisting clients understand the complexities of Medicare,
Medicaid and the many options available to them. This is a service not related to your
disability claim.

Medicare is a government health plan that only provides you with basic insurance coverage. It
doesn't offer other types of medical insurance that you may need, such as dental, vision and
hearing. Insurance Branch specializes in dealing with state, federal and private medical insurance
benefits. If you elect, they can stay in touch with you and provide information necessary to help
you with these choices. If you would like Insurance Branch to assist with this, please sign below:

By signing below, you agree that an authorized representative or licensed insurance agent may
contact you by phone, e-mail or mail to answer your questions and provide additional
information about Medicare, Medicare Advantage, Part D or Medicare Supplemental Insurance
plans.

You also authorize Trajector Disability to share information relating to your Social Security
Disability claim with Insurance Benefits as necessary to discuss and process any insurance
requests.

I give my permission for a representative of Insurance Benefits, or someone they designate,

to contact me by phone, mail, or email about Medicare and Medicare Advantage, Part D or
Medicare Supplemental Insurance plan options once I am successfully granted Social
Security Disability or SSI benefits. This is a solicitation for insurance.

"0 $&3"-"/*&00&,+
{{*(Yes)InsYN_es_:signer1:label("Yes I give permission")}}

, !,+,1$&3"-"/*&00&,+
{{*(No)InsYN_es_:signer1:label("No I do not give permission")}}

Miss Biaca Nicole Bush }}

{{$inssig
Miss Biaca Nicole Bush (Jul 2, 2024 16:03 CDT)
__________________________________
Signature : Biaca Bush (8798)

Jul 2, 2024
{{InsDate_es_:signer1:date:showif(InsYN=Yes)}}
___________________
Date

{{#inssig=SigIns_es_:signer1:signature:showif(InsYN=Yes)}}
 YOU’RE ALMOST DONE!
 Please click the blue button to submit your signed documents.

 If you are on a phone, it is at the top and reads, “Finish”.

 On a computer it is at the bottom and reads, “Click to Sign”.

 If you do not see it, you may have missed a signature. You can
click the blue arrow buttons (on phone), or the “Next” tab
button (on computer), to find where you have missed.

 Please don’t hesitate to call us at 1-800-652-9626 if you need

help. Thank you!