Statement for Determining Continuing Eligibility, Supplemental Security Income Payment--BK & MSSICS Screens

Social Security Administration

IMPORTANT FACTS ABOUT SSI

Things You Need You must report changes to us that affect your SSI. When a change occurs

To Report To Us it must be reported by the 10^th day of the month after the month in which

the change occurred in order to prevent a possible overpayment or penalty.

The easiest way to report a change is to call us toll free at 1-800-772-1213.

If any changes that we list below apply to you, call us right away.

• You move or anyone else moves into or out of the place where you live. Also report births and deaths of people who live with you.

• You get married, divorced, separated, or have your marriage annulled.

• You (or your spouse living with you) start working or the amount of money you earn goes up or down.

• Someone starts or stops helping you pay your bills.

• The amount of other checks or income you (or your spouse living with you) receive goes up or down (pensions, worker’s compensation or unemployment insurance, etc.).

• The value of your resources (things you own) when added together goes over $2,000 ($3,000 if you are married and living with your spouse).

• You (or your spouse living with you) sell, transfer title, dispose of or give away any money or property, including money or property in a foreign country.

• You (or your spouse living with you) leave the place where you live for a full calendar month. For example: You enter a hospital, nursing home, jail, or visit a relative and stay throughout a full calendar month.

• You are released from a hospital, nursing home, jail or other institution.

• You leave the U.S. for more than 30 days in a row. (The U.S. includes the 50 States, the District of Columbia, and the Northern Mariana Islands.)

• You are getting SSI because you are disabled or blind and your health problem improves.

• If a warrant has been issued for your (or your spouse's) arrest because you (or your spouse living with you) were charged or convicted of a crime that carries a sentence of over one year or because you (or your spouse living with you) violated a condition of your probation under federal or state law.

Important Facts You can apply for food stamps at your Social Security office if you and every-

about Food one in your household get or apply for SSI.

Stamps

The Social Security office will help you fill out the food stamp application.

You do not have to go the food stamp office to apply.

F acts About We may use the information you give us when we match records by computer.

Computer Matching programs compare our records with those of other Federal, State, or

Matching local government agencies. Many agencies may use matching programs to find

Programs or prove that a person qualifies for benefits paid by the Federal Government. The

law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us must be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

Important WHAT ARE RESOURCES FOR SSI?

Facts about Resources are things that you (or your spouse living with you) can

Resources use to get food or shelter. Resources can include:

• Cash;

• Real Property, such as a house or land;

• Personal property such as a car, bank accounts, or investments like stocks, bonds or life insurance.

WHAT HAPPENS WHEN YOU GIVE AWAY OR SELL A RESOURCE?

You may not be able to get SSI for a period of time if you, your spouse living with you, or another person gives away your resource or sells it for less than it is worth. This period may be up to 36 months, depending on how much the resource was worth and how much you got for it.

You also may not be able to get SSI if you, your spouse living with you, or someone else puts resources or other things you own or have a right to in trust.

REPORTING TO YOUR STATE MEDICAID AGENCY

SSA uses information about your resources to decide if you can get SSI. SSA also gives your State Medicaid agency information that we have about things you have given away or sold for less than they are worth. Your State Medicaid agency uses this information to decide if you can get Medicaid.

IF YOU HAVE QUESTIONS ABOUT SSI

If you have questions about SSI, including how resources can affect your eligibility, you can contact your local Social Security office or call us toll free at

1-800-772-1213. We will answer your questions about how resources

affect your SSI.

I mportant If you have Medicaid or you are filing for Medicaid, the following information

Information about your assets is important to you.

About

Medicaid WHAT ARE ASSETS FOR MEDICAID?

Your State looks at all your assets when it decides if you can get Medicaid. Your assets can include:

• Money you or your spouse get from wages or self-employment;

• Any other money you or your spouse get, such as money from Social Security, friends or relatives;

• Any free food or shelter you or your spouse get;

• Things you or your spouse own, like bank accounts or real estate;

• Money or property you, your spouse, or someone acting for you placed in a trust; and

• Any money or property which you and your spouse have a right to get but don’t get because of something:

  • You or your spouse did, or

  • Someone else did who was acting for you or at your request.

• Medicaid may count some things as assets that we do not count for SSI.

WHAT HAPPENS WHEN YOU GIVE AWAY OR SELL AN ASSET?

Medicaid may not pay for certain health care for you for a period of time if you, your spouse, or someone else takes an asset of yours and gives it away or sells it for less than what it is worth. Medicaid also may not pay for certain health care if your assets are used to set up a trust that makes payments to someone else or cannot make payments to you for your benefits.

This rule usually applies to people in nursing homes and people in other places, such as hospitals, that give nursing services like those in nursing homes. This rule can also apply to people who:

• Get care at home or in their community under special programs called waivers, or

• Will soon need these services.

At times this rule also applies to people who are getting other kinds of services, such as home health care, help with activities of daily living, or other forms of long-term care.

REPORTING TO YOUR STATE MEDICAID AGENCY

Your State Medicaid agency uses these rules about assets to decide if you can get Medicaid. SSA will give your State Medicaid agency information SSA has about any assets you may have given away. You also must tell your State Medicaid agency any time you give away or sell an asset or set up a trust.

IF YOU HAVE QUESTIONS ABOUT MEDICAID

If you have any questions about Medicaid, including how your assets can affect coverage, please contact the State or local welfare, public health, or social services agency that handles Medicaid. They can answer your questions about how your assets affect your Medicaid.

The Paperwork This information collection meets the clearance requirements of

Reduction Act 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 21 minutes to read the instructions, gather the necessary facts, and answer the questions.

Privacy Act The Social Security Administration is authorized to collect information on this statement under 1611 (c) of the Social Security Act and regulation 20 CFR 416.204. While it is not mandatory except in the circumstances explained below, for you to furnish the information on this statement to Social Security, no benefits can continue unless a periodic review of eligibility is completed by a Social Security office. Your response is mandatory where the refusal to disclose certain information affecting your right to payment would reflect a fraudulent intent to secure payments no authorized by the Social Security Act.

The information on this statement is needed to enable Social Security to determine if the child continues to be eligible for supplemental security income (SSI) payments. Failure to provide all or part of the information could prevent an accurate and timely decision on the child’s continuing eligibility for benefits.

Although the information you furnish on this statement is almost never used for any other purpose than stated in the forgoing, there is the possibility that information may be disclosed to another person or agency as follows: 1. To enable a third party or an agency to assist Social Security in determining continuing eligibility to SSI payments; and 2. To comply with Federal Law requiring the release of information from Social Security records (e.g., to the Department of Veterans Affairs).

Form SSA-8202-BK -SM-FS (07-2004) Page 4