Currently Approved SSA-8282-BK & OCR -- BACKGROUND

FORM SSA-8202-BK

FORM APPROVED
3MB No, 0960-0145

TEL

SOCIAL SECURITY ADMINISTRATION

STATEMENT FOR DETERMINING
CONTINUING ELIGIBILITY FOR SUPPLEMENTAL
SECURITY INCOME PAYMENT
If the name and address below are not correct, please cross out
the part that is wrong and write in the correct information.

WHEN ANSWERING THESE QUESTIONS. REFER TO THIS DATE
1_

SINCE THE DATE ABOVE, have you moved to a new address?
If

YES.’ please give your new address:

ADDRESS Number, Street. City, State, ZIP Code

2-

3.

4.

DATE YOU MOVED

SINCE THE DATE ABOVE, have you spent a full calendar month in a hospital, nursing home or
any place other than whore you live? Also, include trips outside of the United States that lasted 30
days or more.
If "YES’ please give the following information:
NAMES OF PLACES WHEAE YOU STAVED:

ADDRESSES {Number, Street, City State, ZIP Code

DATES FIRST STAYED month/day/year

DATES LEFT month/day/year

LIVES

U

NO

LIVES

fl

NO

i

LIVES

fl

NO

I

LIVES LI

NO

‘

SINCE THE DATE ABOVE, has anyone moved into or out of the place where you live
also, report births and deaths of people living with you?
If ‘"YES," please explain in the REMARKS section on pages 3 and 4 of this form.
SINCE TIlE DATE ABOVE, has anyone given you or your spouse living with you any
money, food, or a free place to live, or helped you pay your bills or your rent?
If YES, please give the following information:
TYPE OF HELP

6.

HOW OFTEN YOU RECEIVED HELP

AMOUNT OF HELP

SINCE THE DATE ABOVE, have you, or your spouse living with you, earned
money from working or do you expect to earn money from working in the next
14 months? DO NOT COUNT earnings from self-employment.
If you have earned money from working, please give the following information:
a- Amounts of Earning for Past Months:
Gross Wages
Employers
Name of Worker
Name. Addros, and Phone Number

Amount

Dates of
Employment

How Often Paid

From:
To:
Era n:
To:
Form

SSA-8202-BK

03-2002 Er 07-2002

Destroy Prior Editions

PAGE 1

b. Estimates of Earnings for this Month and Future Months

Amount

Month

Month

Month

Month

Month

Month

Month

$

$

S

S

$

S

S

Month

Month

Month

Month

Month

Month

Month

s

s

Amount

6

SINCE DATE ON PAGE 1. have you, or your spouse living with
or expect to be self-employed in the current taxable year?
If YES, ease give the following information:
Typo of
Income

Name of SellEmployed Person

Last Years
Gross
Net Income
Income
or Loss

you,

been self-employed

flYESfl NO

This Years Estimated
Gross
Net Income
Income
or Lossi

Dates of SelfEmploynent
Fran:
To:
From:
To:

SINCE DATE ON PAGE 1, have you, or your spouse
the following payments?
* Support alimony. child support
*
*
* Interest/dividends from bank accounts
*
* Any other cash payments or chocks
*
gifts. sick benefits, unemployment, or
workers compensation
DO NOT COUNT

-

living with you, received any of
DYESLJNO
Rental Income
Pensions/Annuities
Temporary Assistance for Needy Families
Other

Social Security, $81. Food Stamps, Federal Civil Service Pensions. Railroad
Retirement, Temporary Assistance for Needy Families or Veterans’ Benefits

If you or your spouse living with you RECEIVED ANY OF THE PAYMENTS LISTED ABOVE,
please give the following information;
TYPE OP PAYMENT RECEIVED

PAYMENT AMOUNT

HOW OFTEN RECEIVED

a. Do you, or your spouse living with you, have any checking or Savings accounts
or any other funds in the bank? Include any accounts where you hove direct deposit
of any money.

‘

LIysL1 NO

If YES, please give the following information:
Name and Address of Financial Inslitution

Type of Account

Account eatance

b. Does your name or the name of your spouse living with you, appear on any other account
that you do not consider your own? Include any accounts where you have direct deposit of
any money.

LJYESLI NO

If YES. p’ease give the following information
Name and Address at FinanclI Instinitior.

form

SSA-8202-BK

03-2002 EF 07-2002

Type at Account

Account Baance

PAGE 2

9

Do you, or your spouse living with you, have any cash at home, stocks, bonds, notes, or
certificates of deposit?

i

LIVES

DNa

If YES, please give the following information:
WHAT YOU HAVE

THE VALUE OF WHAT YOU HAVE

10. Do you, or your spouse living with you, own any land or buildings or does your name appear
on a deed or mortgage of any land or building where YOU DO NOT LIVE?

flVES DNa

This includes inherited property, property outside the United States and/or any property your name
is on with other members of your family.
ii. SINCE THE DATE ON PAGE 1, have you or your spouse living with you sold, transferred title,
disposed of, or given away any money, or other property, including money or property in toreign
countries?
‘
If YES, please give the following information:
WHAT YOU SOLD, TRANSFERRED TITLE,
DISPOSED OF. OR GAVE AWAY

flVES JNO

THE VALUE OF THE PROPERTY

12. SINCE THE DATE ON PAGE 1. have you or your spouse living with you had any change
in health insurance coverage or other insurance that pays for medical bills?
DO NOT INCLUDE Medicare or Medicaid
DO INCLUDE-- Insurance, such as accident, automobile, or casualty if it covers medical bills
for any reason.

r

LIVES flNO

--

IF YOU LIVE IN CALIFORNIA. PLEASE DO NOT ANSWER QUESTION 13 BELOW.
You

Form

Your Spouse

a. Are you currently receiving food stamps?
If YES, go to b." If NO, go to ‘c.’

I

EYES

9 NO

flYES

NO

b. Have you received a recertification notice within the past 30 days?
If YES, go to "e." If NO, go to question 14.

*

flVES

fl NO

EYES

NO

c. Have you filed for food stamps in the last 60 days?
If YES, go to d.’ If NO. go to "e.’

P

JJYES flNO flVES ONo

d. Have you received a favorable decision?
If YES, go to question 14. If NO. go to "e."

.

flvrs

fl NO

flYES

fl NO

e. Is everyone in the household applying for or receiving SSl?
If YES go to "f.’ If NO. go to question 14.

‘

DYES

fl NO

9YES

LI NO

f. May I take your food stamp appIkation today?
It YES, go to question 14. If NO, explain in "g.
g. Exp’anation

I

flYES

DNa

EYES LINO

SSA-8202-BK

O3-2OO2J Er 07-2002

PAGE 3

14. Please answer the following questions:
a. Are you age 62 or older?

flYES flNO

b. If you are age bOor older, are you a widowler?

flYES flNO

c. If you are age 50 or older and divorced, is your divorced spouse deceased?

DYES DNO

d. If you were disabled before age 22, do you have a parent who is age 62 or older,
or disabled, or deceased?

I

DYES UNO

15. SINCE THE DATE ON PAGE 1. has a warrant been issued for your arrest in connection with a
crime, or an attempt to commit a crime, that is a felony or in New Jersey, a high misdemeanor a
for violation of a condition of probation or parole under Federal or State law?
DYES JNO
If the address where you live is different from the address where you get your mail, please give the address whore
you live:
Address Number, Street, City, State, ZIP Code

PAPERWORK REDUCTION ACT; This i9formation coUpdon meets th$learance requirements of 44 U.S.C. §3507 as amended
by Section 2 of the Paperwork R,ductionftt of 1995. 7&u are not io6ired to answer these questions unless we display a valid
Office of Management and Budgt contryl’number. Wcptiniate that it%ilI take you about it minutes Lo read the instructions, gather
‘4
eVic&
.:lLj
the necessary facts, and answer the qytions.
REMARKS

Form

SSA-8202-BK

O3-2QO2 EF 07-2002

PAGE 4

REMARKS Continued

IMPORTANT INFORMATION

--

PLEASE READ CAREFULLY

*

Failure to report any change within 10 days after the end of the month in which the change occurs could result in
a penalty deduction.

*

If you are disabled or blind, you must continue to accept any appropriate vocational rehabilitation services offered
to you by the State agency to which we refer you.
AUTHORIZATIONS/SIGNATURES Write in Ink

I/we give permission for the Social Security Administration to check the information I/we have given on this form and
to ask my employers for information about my wages.

I/we understand that anyonewho knowingy lies or misrepresents the truth or arranges for someone to knowingly lie
or misrepresent the truth is committing a crime which can be punished under Federal law. State law, or bath.
Everything on this statement is the truth as best I/we know it.
RECIPIENT SIGNATURE Write in ink
Your Signature First name, middle initiaL last name
Date
.

Area Code and Tele
phone Number Where

You Can Be Reached

Spouses Signature First name, middle initial, last name Sign Only it Receiving Date
SSI Payments}

Sign

I.

HereF

WITNESSES Write in ink
If you sign by nark X’, two people who know you must witness your signing. the witnesses must sign below and give their tull names and
addresses.

2 Signature of Witness

1. Signature of Witness

Address Number, Street. City, State, ZIP Code

Your Title or Relationship to the Recipient

Address Number. Street, City, State, ZIP Code

REPRESENTATIVE PAYEE Write in ink
Area Code and Telephone Number
Address INumber, Street, City. State. ZIP Code

Where You Can Be Reached

C
Your full name First name,

middle initial,

last name

}
Date

Please print here

Please sign here

Form SSA-8202-BK 03-2002 CF lO7-2OO2

PAGE 5

KEEP THIS PAGE FOR YOUR RECORDS
SOCIAL SECURITY NUMBER

NAME

/

SOCIAL SECURITY NUMBER

NAME

/
Telephone Number include rea codel to call
if you hove a qLstion or something 10 report

Privacy Act
Notice

DATE

/
/

Social Security Office you may visit in person or mail things to!

The Social Security Administration is authorized to collect the information on this statement under 16l1c of the
Social Security Act and regulations 20 CFR 416204. While it is not mandatory except in the ciwumstances
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 not authorized by the Social Security Act.
The information on this statement is needed to eirnble Social Security to determine if you continue to be eligib2e for
supplemental security income 551 payments. Failure to provide all or part of the infonnation could prevent an
accurate and timely decision on your continuing eligibility for benefits.
Although the information you furnish on this statement is almost never used for any other purpose than stated in the
foregoing, there is a possibility that information may be disclosed to another person or to an 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
COMPUTER MATCHING We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local government agencies. Many
agencies may use matching programs to find or prove that a person qualiries 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 may be used or given out are available i.
Social Security offices. If you want to learn more about this, contact any Soctal Security office.
You Must
Report
Cerlam
Chan

The amount of your 551 check is based on the information you tell us. To continue getting the right
payment amount, you must report certain changes that happen to you.
You must tell us about changes within 10 days after the month they happen. If you do not report
changes, we may have to take as much as $25. $50, or $100 out of future checks you receive.
You must also report changes in income for your ineligible spouse or children who live with you, or your sponsor or
sponsors spouse if you are an allow You must also report if any of these people buy or sell anything of value.
Remember, changes could make your check bigger or smaller. A List of Most of the Changes You Must Report Is
On The Next Page.

How To
Report
Changes

There are several ways you can report changes;
*

*
*
Are You
Working
or Would
You Like
to work

Call us, toD free, at 1-800-772-1213.
Call your local Social Security Office at the number above.
By mail or in person see the address above.
-

If you would like to work or if you are already working and would like to earn more, you should know about 551
mles kno’*,i as work incentives. These rules can help you keep your Medicaid and help you keep getting some 551
even though you are working.
If you want to know more about these rules, call us, toll free, at 1-800-772-1213 or write or visit any Social
Security office.
If you call or visit ask to speak to someone about work incentives.

Important
Facts About
Food Stamps

You can apply for food stamps at the Social Security Office if you and everyone in your household get or apply for
SSI.
The Social Security Office will help you fill out the food stamp application. You do not have to go to the food stamp
office to apply.

Form SSA-8202-RK 103-2002 EF 07-2002

PAGE 6

CHANGES TO REPORT

[El

WHERE YOU LIVE You must rejmrt to Social Securit, if:
-

*
*

El

You move,

*
*

You or your spouse leave your household hr
a calendar month or longer. For example.
you enter a hospital or visit a relative.

*
*

You
You
You
You

leave the United States for 30 days or more.
enter ajail, prison. or other penal institution.
are released from a hospital, nursing home, etc.
are no longer a legal resident of the United States.

HOW YOU LIVE You must report to Social Security if:
-

*

Someone moves into or out of your household.

*

The amount of money you pay toward household
expenses changes.

*

There are births and deaths of any people with
whom you live,

INCOME
*

You must report to Social Security If:
The amount of money or checks or any other type
or payment you receive Irom someone or som,lace
goes up or down or you start to re’ve money or
checks or any other type of payment.

*

Your marital status changes:
You get married, separated, divorced, or your marriage
annuuei
You separate from your spouse or start liwog together
again after a separation.
You begin living with someone as husband and wife.

*

You start work or stop work.
Your earnings go up or down.

-

*

El

HELP YOU GET FROM OTHERS You must report to Social Security Th
* The amount of help money, food, clothing, or
*
Someone stops helping you.
payment of household expenses you receive
*
someone starts helping you.
goes up or down.

[EJ

THINGS OF VALUE THAT YOU OWN You must report to Social Security if:
* lie value of your resources goes over $2,000
*
You sell or give any things of value away.

-

-

when you add them all together $3,JX if you
are married and live with your spouse.

*

You buy or are given anything of value.

El

A WARRANT HAS BEEN ISSUED FOR YOUR ARREST - You must report to Social Security if:
* You flee prosecution or to avoid custody or confi*
You violate a condition of your parole or probation under
ment after conviction for a crime, or an attempt to
Federal or Slate law.
commit a crime, which is a felony or in New Je[sey.
a high misdemeanor.

i:i

YOU AJ1E BLIND OR DISABLED - You must report to Social Security
* Your condition improves or your doctor says you
can return to work.
*

i:i
i:i
[J
Form

You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22
*

if:

You are under age 18 and live with your parents,
ask your parents to report if they have a change in
ilrome. a change in their marriage, a change in the
value of anything they own, or either has a change
in residence.

-

You must report to Social Security if:
*

You get married.

*

There are changes in the income, school attendance if
between the ages of 18 and 21, or marital status of
ineligible children who live in your household.

YOUR IMMIGRATION AND NATURALIZATION SERVICE INS STATUS CHANGES

-

You must report any

changes to Social Security.

YOU ARE A REPRESENTATIVE PAYEE

-

You must report to Social Security if:

*

The person for whom you receive SSI checks has any of the changes listed above. You may be held liable if you do
not report changes that could affect the SSI recipient’s payment amount, and he/she is overpaid.

*

You will no longer be able or no longer wish to act as the person’s representative payee.

SSA-8202-BK 03-2002

EF 07-20021

PAGE 7

Thefollowing revised PRA Statement will be inserted into theform at its
next scheduled reprinting:
Paperwork Reduction Act Statement This information collection meets the
requirements of 44 U.&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
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies ill your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments
on our time estimate above to: 514, 1338 Annex Building, Baltimore, MD 21235-0001.
Send Q– comments relating to our time estimate to this address, not the completed
form.
-

FORM SSA-8202-OCR-SM

Social Security Administration

8202

Fan,. Approved
0MB No. 8O-O145

1

STATEMENT FOR DETERMINING CONTINuING ELIGIBILITY
FOR SUPPLEMENTAL SECURITY INCOME PAYMENTS
PRIVACY ACT/PAPERWORK ACT NOTICE: I understand that my resporEe is votuntory hut: 1 thai the ijifontadon requetsd below is needed to determine my
continuing eligibility to Supplemental Security Income and/or State supplementary payments - may result in an adjuatnent of ray paynian 2 that thia information may be
used in determining my eligibility for State Medineid or Social Sens; and a that no further benefits n be paid under the Supplemental Security Income/or State
Supplemental pmgrams unless this form is mpIeted andfiledas required byexisting law and regulations aection 1611c of the Soal Sacuri Airt and regulations
20 CPR 416.204. The routine uses for the inlbrmation obtained am tally explained and puhlished annually in The Fed.l Rister. Phe SocialSecuriiy Administration will
further explain theae uses Ulkn request.

DRDP:
RUN:
JD:
STC:
WI:
TN:
FLA:

PROFILE:
DOC:
CFL:
HUN:
FUN:
TMR;
RETURN THIS FORM WITHIN 30 DAYS

LANOPREF;

HUSBAND’S/WIFE’S NM4E

SOCIAL SECURITY NUMBER SSN

HUSBAND’S/WIFE’S SOCIAL SECURITY NUMBER

IF YOUR NAME AND ADDRESS SHOWN ABOVE ARE NOT CORRECT, CROSS OUT THE PART
THAT IS WRONG AND WRITE IN TH} CORRECT INFORMATION
I understand that the Social Security Administration will also compare its records with
records from other State andior Federal agencies to make sure I am paid the correct amount.
Yes

PRINTANSWERSLIKETHIS

1.

Since

OI1I2I3I4I56I78I9I

No

ORLIKEThISfl

have you moved to a new address?

Yes

No

Yes

No

If "YES. please give:
DATES YOU MOVED

NEW ADDRESS

2-

Since
have you spent a flI calendar month in a hoepitai,
nursing home, other institution or any place other than where you live?
Include trips outside the U.S.. If"yes" were you in:

U

Hospital

Nursing Home

DATES ENTERED

Month

U

Institution

Day

U

Outside U.S.

Year

Other

DATESS LEFT

I I hi i i/I I I I I
8202

Month

Day

I I hi I

NAMES AND ADDRESSES OF INSTITUTIONS

Form SSA-8202.OCR’SM 10.2003

U

-

1

ui

Year

I I I I

$202 2
-

3.

Since
has anyone moved into or out ofthe place where you live? also
report births and deaths

4.

Since
work?

5.

Since
has anyone NOT LIVING WITH YOU given you any money or
helped pay your bills?

-

6.

have

you or your spouse

INTEREST
INCOME

OTHER

U

U
*

No

In

I I P I6

ADDRESS CF BANK

NAME OF BANK

0

I0
Yes

ACCOIWF
BALANCE

LI II I P I

GIVE
ACCOUNT
EALAIICE

I II I I I

Does yotir name or the name ofyour spouse living with you appear on any other
savings OR checking accounts that yon DO NOT consider your own? Include
accounts where you have DIRECT DEPOSITS.
IfYES’, give name and address of all hanks or savings institutions:
ADDRESS OF BANK

NAME OF BANK

ADDRESS OF BANK

Yes

CDs

O?FBER

U

U

No

GIVE
ACCOUNT
BALANCE

>1 I II I I I

GIVE
ACCOUNT
BALANCE

‘I I II I I

OTHER THAN your checking or savings accounts, do you or your spouse
living with you have any other money? Examples: cash at home, stocks.
bonds, motes. ertiflcaros ofdeposit,
IF ‘yES" LIST WHAT YOU HAVE
CMII STOCKS OoNI NOT

No

GIVE

ADDRESS OF BANK

NAME OFEAt4K

No

Do not write in
this space

Do you or your spouse living with you have any savings OR checking accounts?
Include accounts where you have DIRECT DEPOSITS.
If"YES", give name and address Mall banks or savings institutions:

EEDU

Yes

THIS RECEIVED?

Ifyou have $600, it would
beprintedlikethis
SHOW DOLLARS ONLY

NAME OF DANK

9.

No

FLOW OFTEN WAS

PAYMENT
.uiourn

-

Yes

HOW OFTEN DrD YOU RECEIVE THIS HELP?

Since
have you or your spouse living with you received support
payrnent. rental income, or any other money payments OR received a private
pension or annuity from a Federal, State, or Local Government? DO NOT
INCLUDE: Social Security. 551, Welfare Food Sttmps, VA or Railroad Benefits.

ExanwIe For items 7,
SandS

No

U U

living with you earned money from

IF "YES, WHAT KIND OF HELP?

[F ‘YES". WHAT WAS RECEIVED?

‘7.

Yes

Yes

No

V AWE

‘0.

Do you or your spouse living with you own or partly own any land or buildings
where YOT3 DO NOT LIVE? Including inherited property and any real estate
with your name on the deed or mortgage NOT counting the place where you livt

Yes

No

1L

Since
have you cold, trapsfrred any title, disposed ofor given away
any money, or other property. including money or property in treign
countries?

Yes

No

Farm SSA-8202-OCR-SM l0-20

8202-2

18202-3
12.

1&a.

No

English

D

Spanish

D

Ye.

No

Other Write in name of language

Which language do you prefer us to use when writing to you?

U
14.

Ye

Wbich language do you prekr to use when speaking to us?

U
lab.

I

Sitice
have you or your spouse living with you had any change in
health inanrance covorage or other insurance that pays fir nedioalbills?
DO NOT INCLUDE Medicare, but DO INCLUDE insurance such as
accident, automobile, or casualty jut covers medical bills Sr any reason.

English

U

Spanish

U

Other write in name of language

Since
,has a warrant been issued forycur or your spouse
living with you arrest in connection with a crime, or an attempt to
commit a crime, that is a felony or in New Jersey, a high
miademenor or thr violation ofacondition ofprohation or parole
under Federal or State law?

-

I understand that the Social Security Administration will also compare its records with
records from other State and Federal agencies to make sure I am paid the correct amount.

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application
or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal or
State law or both. I affirm that all information I have given in this document is true.
SIGNATURES
YOUR SIGNATURE If yo sigit with o’z rhove flto peopk witness below.

DATE

SiGN
HERE
HUSBANDS OR WIFE’S SIGNATURE

PHONE NUMBER AT WHICH YOU CAN BE
REACHED lad the area code

SIGN

HERE

ENONE

WITNESSES

YOUR STATEMENT 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 OP WITNESS

ADDRESS

ADDRESS

if YOU ARE THE REPRESENTATIVE PAYEE MiD ARE FILING

TInS STATEMENT ON BEHALF OF ANOTHER PERSON GIVE:
DATE

YOUR FULL NANE PRINT
AND

SIGN
H ERE
YOUR TITLE OR RELATIONSHIP TO RECIPIENT

PHONE NUMBER AT WHICH YOU CAN BE
REACHED Include area code

NONE
Form SSASO2-OCH-SM l23

8202-3

8202-4

FOR SSA USE ONLY
WBDOC LI
FO

Form SSA-g202-OCN-SM IO-20U3

8202

-

Thefollowing revised PEA Statement will he inserted into theform at its
nat scheduled reprinting:
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 9
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURJTY
OFHCE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments
on our time estimate above to: LISA, 1338 Annex Building, Baltimore, MD 21235-0001.
Send
comments relating to our time estimate to this a4dresy, not the completed
form.
-