Form ssa 5666-2026

1. Click ‘Get Form’ to open the SSA 5666 in the editor.
2. Begin by entering the claimant's name and the requesting office's name and address at the top of the form.
3. In Section 1, indicate if there has been any recent evaluation or testing of the child. If yes, specify the type of test and date.
4. Proceed to Section 2 to note if the child has been referred for assessment or special services, including relevant dates.
5. Fill out Section 3 with current instructional levels in reading, math, and written language, including scores and assessment instruments used.
6. In Section 4, check any grades that have been repeated by the child.
7. Section 5 requires you to list any educational disabilities. Check all that apply and provide specifics where necessary.
8. Complete Section 6 by checking applicable placement and related services, indicating hours per week as needed.
9. Use the additional comments section for any further information that may assist in evaluating the child's functioning.
10. Finally, provide your name, title, and contact information on the last page before submitting.

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