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pdfFORM APPROVED
OMB No. 0960-0416
UPDATE
SOCIAL SECURITY ADMINISTRATION
STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY
FOR SUPPLEMENTAL SECURITY INCOME PAYMENTS
For Official Use Only
EI SSN
Spouse's Name
Name and Address
Spouse's SSN
Check the Ones That Apply
NC
C
M
DO Code
N
FS-APP
FS-REF
Interviewer's Initials
Date Received
WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE
1.
2.
3.
MARITAL STATUS/TRAVEL OUTSIDE THE UNITED STATES/LIVING ARRANGEMENTS
Since the date above, has your marital status (or the marital status of your parents if you are a child)
changed?
Since the date above, have you moved to a new address?
If "yes," give the new address:
ADDRESS (Number, Street, City, State, and ZIP Code)
DATE YOU MOVED
Since the date above, have you been outside the United States (the 50 States, District of Columbia, and
Northern Mariana Islands)?
If "yes," please give:
DATE(S) LEFT (month/day/year):
4.
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
DATE(S) RETURNED (month/day/year)
Since the date above, have you spent a full calendar month in a hospital, nursing home, or other
institution?
If "yes," please give:
NAME OF INSTITUTION
Yes
DATE ENTERED (Month/day/year): DATE LEFT (Month/day/year):
ADDRESS (Number, Street, City, State and ZIP Code)
5.
Mark X in the box which best describes where you live:
6.
Since the date above, has anyone moved into or out of the place where you live? (including births and
deaths) If "yes," please give:
House
Apartment
Room
Mobile Home
Nursing Home
Rest or Retirement Home
BLIND OR
NAME
7.
RELATIONSHIP AGE DISABLED
YES NO
Hospital
Rehabilitation Center
DATE MOVED
IN
School
Other
INELIGIBLE CHILD
DATE MOVED
OUT
STUDENT MARRIED INCOME
Do any other people live in the same household with you or your spouse?
If "yes," please give the following information about them (including children):
BLIND OR
NAME
Form
(specify)
SSA-8203-BK
RELATIONSHIP
(8-2006) EF (08-2006) Destroy Prior Editions
INELIGIBLE CHILD
AGE AND/OR DISABLED
DATE OF BIRTH
YES NO STUDENT MARRIED INCOME
Page 1
8.
LIVING ARRANGEMENTS (continued)
Do all of the people who live with you receive public assistance payments?
(For example, welfare, TANF, VA pension, general assistance, SSI.)
9.
a. Do you, or your spouse living with you, own or are you buying the place where you live?
If "yes," give:
Yes
No
Yes
No
b. Do you, or your spouse living with you, rent the place where you live?
Yes
No
c. If you are a child recipient living with your parents, do your parents own or rent the place where you live?
Yes
No
d. Does someone else who lives with you own or rent the place where you live?
Yes
No
Yes
No
Yes
No
Since the date on page 1, did anyone not living with you:
a. Give you a free place to live?
Yes
No
b. Help you pay the mortgage, rent, property insurance, property taxes, and/or sewerage charges?
Yes
No
c. Give you or help you pay for food, gas, electricity, heating fuel, water, and/or garbage collection service?
Yes
No
Yes
No
Yes
No
MONTHLY MORTGAGE PAYMENT AMOUNT:
e. If the place where you live is rented give,
LANDLORD'S NAME
LANDLORD'S
PHONE
ADDRESS
(Number, Street, City, State and ZIP Code)
MONTHLY
RENT
( )
f. If the place where you live is rented, are you (or anyone living with you) the parent or child of your
landlord or your landlord's spouse?
If "yes," give the name of the household member who is the
related person
g. If a. or b. is answered "yes," does any one who lives with you (other than your spouse) pay for or give
you money for food, mortgage or rent, property insurance or taxes, heating fuel, gas, electricity, water,
sewerage, or garbage collection services?
10.
If "yes," to a., b., or c., complete the following:
SOURCE
TYPE OF HELP
NAME/ADDRESS (Number, Street, City, State, ZIP Code)
PHONE
NUMBER
MONTHLY
AMOUNT
MONTHS
RECEIVED
( )
( )
( )
11.
Since the date on page 1, did anyone give you other gifts which are not cash?
If "yes," complete the following:
DESCRIPTION OF
ARTICLE
SOURCE
NAME/ADDRESS (Number, Street, City, State, ZIP Code)
PHONE
NUMBER
MONTHS
RECEIVED
VALUE
( )
( )
12.
EARNED INCOME
Since the date on page 1, have you, or your spouse living with you, worked OR do you expect to
work in the next 14 months?
If "yes," please give:
a. Amounts for Past Months
NAME OF
WORKER
EMPLOYER'S NAME, ADDRESS (Number, Street, City,
State, ZIP Code) AND PHONE NUMBER
GROSS WAGES
How
Often
Amount
Paid
DATES OF
EMPLOYMENT
From:
To:
From:
To:
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Page 2
12.
EARNED INCOME (continued)
b. Estimates for Current and Future Months
Month
Amount
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Month
Amount
13.
Since the date on page 1, have you, or your spouse living with you, been self-employed or expect to be
self-employed in the current taxable year?
If "yes," please give:
Yes
No
Yes
No
a. Private pensions, annuities (other than Social Security, SSI, or food stamps)?
Yes
No
b. Unemployment or worker's compensation?
Yes
No
c. TANF or State or local assistance based on need?
Yes
No
d. Veterans Administration benefits (based on need, not based on need, education)?
Yes
No
e. Rental/lease income?
Yes
No
f. Alimony or child support?
Yes
No
9. Dividends or royalties?
Yes
No
h. Interest earned on money in bank accounts (including interest on checking accounts)?
Yes
No
i. Money from a trust fund?
Yes
No
j. Money from any other person or organization?
Yes
No
LAST YEAR'S
NAME OF SELF-EMPLOYED
PERSON
TYPE OF BUSINESS
GROSS
INCOME
THIS YEAR'S ESTIMATED
NET INCOME
(OR LOSS)
GROSS
INCOME
DATES OF SELFEMPLOYMENT
NET INCOME
(OR LOSS)
From:
To:
From:
To:
14.
If you are disabled, do you have any special expenses that you paid that are related to your illness or injury
and which are necessary for you to work?
UNEARNED INCOME
15.
Since the date on page 1, have you, or your spouse living with you, received, or do you expect to receive
in the next 14 months, any of the income listed below:
If the answer is "yes," to any of these types of unearned income, please give:
TYPE OF
INCOME
RECEIVED BY
AMOUNT
FREQUENCY
DATES RECEIVED OR
EXPECTED
From:
To:
From:
To:
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Page 3
SOURCE (Name/Address of Person
Bank, Company, or Organization)
16.
RESOURCES: THINGS YOU OWN
Do you, or your spouse living with you, own any of the following items (answer "yes" if your name appears
alone or with any other person as the owner or part owner of any of these items):
a. Cash (with you, at home, in a safe deposit box)?
Yes
No
b. Checking accounts?
Yes
No
c. Savings accounts?
Yes
No
d. Credit union accounts?
Yes
No
e. Christmas club accounts?
Yes
No
f. Savings certificates/certificates of deposit?
Yes
No
g. Promissory notes or IOU's?
Yes
No
h. Stocks or bonds?
Yes
No
i. Other items that can be cashed or sold?
Yes
No
If "yes," please give the following information:
NAME OF
EACH ITEM
17.
OWNER(S) OF
EACH ITEM
TOTAL VALUE
OF EACH ITEM
NAME AND ADDRESS OF BANK,
COMPANY, OR ORGANIZATION
Do you, or your spouse living with you, own or are you buying any life insurance policies?
Yes
No
Yes
No
Yes
No
If "yes," please give the following information:
NAME OF OWNER
NAME OF INSURED
TOTAL FACE VALUE CASH SURRENDER
WHEN WAS THE
IF THERE IS A LOAN AGAINST
OF POLICY
VALUE
POLICY PURCHASED THE POLICY, GIVE THE AMOUNT
POLICY NUMBER
18.
NAME AND ADDRESS OF INSURANCE COMPANY
Is your name, or the name of your spouse living with you, on the title of any vehicles (for example, car,
truck, boat, camper, motorcycle, etc.)? If "yes," please give the following information:
YEAR OF
VEHICLE(S)
NAME OF OWNER(S)
MAKE AND MODEL
CURRENT
MARKET VALUE
HOW MUCH IS OWED
ON VEHICLE(S)
MAIN PURPOSE FOR WHICH THE VEHICLE(S) IS USED (For example, employment, to obtain medical treatment, etc.)
19.
Do you, or your spouse living with you, own or are you buying any real estate (land or buildings or other
structures on the land)? (Include property outside the U.S., inherited property, life estates. Do not include
your home.) If "yes," please give the following information:
NAME OF OWNER
ESTIMATED CURRENT
MARKET VALUE
DESCRIPTION (Include type and size of structures,
acreage or lot size, and location of property)
Form
SSA-8203-BK (8-2006)
EF (08-2006)
TAX ASSESSED
VALUE IF KNOWN
AMOUNT OF MORTGAGE PAYMENT (If
AMOUNT OWED ON
THE PROPERTY
USE (Describe how the property is used. If not in use, give
date of last use and next planned use.)
Page 4
20.
RESOURCES (continued)
Do you, or your spouse living with you, own any of the following items (answer "yes" if your name or your
spouse's name appears alone or with any other person as the owner or part owner of any of these items).
a. Other household or personal items not already mentioned worth more than $500?
Yes
No
Yes
No
Yes
No
Yes
No
You
Yes
No
Your Spouse
Yes
No
You
Yes
No
Your Spouse
Yes
No
b. Other equipment (business or nonbusiness) or property of any kind (not already included on this form)?
If "yes," please give the following information:
OWNER(S) OF EACH ITEM
NAME OF EACH ITEM
DESCRIPTION (Where appropriate, give name
and address of bank, company, or organization)
21.
TOTAL VALUE
OF EACH ITEM
HOW MUCH IS OWED ON
EACH ITEM
USE (Describe how the property is used. If not in use,
give date of last use and next planned use.)
a. Do you, or your spouse living with you, own any headstones or markers, cemetery lots, crypts, urns,
mausoleums, or other repositories for burial?
If "yes," please give:
NAME OF OWNER
FOR WHOSE BURIAL
RELATIONSHIP TO YOU
OR YOUR SPOUSE
DESCRIPTION AND VALUE
b. Do you, or your spouse living with you, have any money or other assets, such as, burial contracts,
trusts, insurance policies, agreements, or anything else you intend to use for your burial expenses?
(Include assets listed in items 16-21 if appropriate.)
If "yes," please give:
DESCRIBE WHAT YOU HAVE SET ASIDE
IS IT IRREVOCABLE
YES
22.
NO
VALUE
WHEN DID YOU SET IT
ASIDE (Month/Day/Year)
NAME OF OWNER
WILL INTEREST EARNED OR APPRECIATIONS
IN VALUE REMAN IN THE BURIAL FUND
YES
NO
FOR WHOSE BURIAL
a. 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 foreign countries?
b. If you co-owned property with another person(s), did you or any co-owner sell, transfer,
or give way any co-owned money or property?
IF "YES" TO (A) OR (B), GO TO (C). IF NO TO BOTH, GO TO 23.
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Page 5
RESOURCES (continued)
22.
Cont.
GIVEN
AWAY
SOLD ON
OPEN MARKET
TRADED FOR
GOODS/SERVICES
DESCRIPTION OF PROPERTY
VALUE OF PROPERTY AND/OR
SALE PRICE OR OTHER
AMOUNT OF CASH GIFT
CONSIDERATION RECEIVED
OWNER'S/CO-OWNER'S NAME(S)
NAME AND ADDRESS OF
PURCHASER OR RECIPIENT
DATE OF
DISPOSAL
RELATIONSHIP
TO OWNER
ARE ADDITIONAL CONSIDERATION OR PROCEEDS EXPECTED?
EXPLAIN
DO YOU STILL OWN PART OF THE PROPERTY? IF YES, EXPLAIN
23.
Yes
No
Yes
No
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, but do include insurance
such as accident, automobile, or casualty if it covers medical bills for any reason.)
Yes
No
IF YOU LIVE IN CALIFORNIA, PLEASE DO NOT ANSWER QUESTION 24 BELOW.
You
24.
a. Are you currently receiving food stamps?
If YES, go to "b." If NO, go to ''c.''
YES
NO
YES
NO
b. Have you received a recertification notice within the past 30 days?
If YES, go to "e." If NO, go to question 25.
YES
NO
YES
NO
c. Have you filed for food stamps in the last 60 days?
If YES, go to "d." If NO, go to ''e.''
YES
NO
YES
NO
d. Have you received a favorable decision?
If YES, go to question 25. If NO, go to "e."
YES
NO
YES
NO
e. Is everyone in the household applying for or receiving SSI?
If YES, go to "f." If NO, go to question 25.
YES
NO
YES
NO
f. May I take your food stamp application today?
If YES, go to question 25. If NO, explain in "g."
YES
NO
YES
NO
g. Explanation
Form
Your Spouse
SSA-8203-BK (8-2006)
EF (08-2006)
Page 6
25.
a. Which language do you prefer to use when speaking to us?
b. Which language do you prefer us to use when writing to you?
26.
27.
Please answer the following questions:
a. Are you age 62 or older?
Yes
No
b. If you are age 50 or older, are you a widow(er)?
Yes
No
c. If you are age 50 or older and divorced, is your divorced spouse deceased?
Yes
No
d. If you were disabled before age 22, do you have a parent who is age 62 or older, disabled, or
Yes
deceased?
You
(a) Do you have any unsatisfied felony warrants for your
Your Spouse, if filing
arrest?
YES
NO
YES
NO
Go to (b)
Go to (b)
Name of State/Country
(b) In which state or country was this warrant issued?
No
Name of State/Country
Go to (c)
Go to (c)
(c) Was the warrant satisfied?
(d) Date warrant satisfied:
28.
YES
Go to (d)
month, day, year
(a) Do you have any unsatisfied Federal or State warrants for
YES
violating the conditions of probation or parole?
Go to (b)
NO
You
NO
YES
Go to (b)
YES
Go to (d)
(d) Date warrant satisfied:
month, day, year
REMARKS
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Page 7
NO
NO
Name of State/Country
Go to (c)
(c) Was the warrant satisfied?
NO
Your Spouse, if filing
Name of State/Country
(b) In which state or country was the warrant issued?
YES
Go to (d)
month, day, year
Go to (c)
YES
Go to (d)
month, day, year
NO
REMARKS Continued
If the address where you live is different than the address where you get your mail, please give the address where you live:
Address (Number and Street)
City/State
ZIP Code
YOUR AUTHORIZATION
I give my permission for the Social Security Administration to check the information I have given on this form, and to ask my
employer(s) for information about my wages. I understand that the Social Security Administration will compare its records with
records from other State and Federal agencies to make sure I am paid the correct amount of benefits. 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 or misleading statement about a
material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other
penalties, or both.
SIGNATURES (Write in ink)
Your Signature (First name, middle initial, last name)
Area Code and TeleDate
phone Number Where
You Can Be Reached
Sign
Here
Spouse's Signature (First name, middle initial, last name) (Sign Only if Receiving Date
SSI Payments)
Sign
Here
(
)
WITNESSES (Write in ink)
If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign below and give their full names and
addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
Address (Number, Street, City, State, ZIP Code)
REPRESENTATIVE PAYEE (Write in ink)
Your Title or Relationship to the Recipient
Area Code and Telephone Number
Where You Can Be Reached
(
)
Your full name (First name, middle initial, last name)
Date
Please print here
Please sign here
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Address (Number, Street, City, State, ZIP Code)
Page 8
RIGHTS AND RESPONSIBILITIES
NAME
SOCIAL SECURITY NUMBER
DATE
NAME
SOCIAL SECURITY NUMBER
DATE
-
Telephone Number (include area code) to call
if you have a question or something to report.
(
-
Social Security Office you may visit in person or send in your request:
)
Privacy Act
Notice
The Social Security Administration is authorized to collect the information on this statement under 1611(c) of the
Social Security Act and regulations 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 not authorized by the Social Security Act.
The information on this statement is needed to enable Social Security to determine if you continue 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 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 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 may be used or given out are available
in Social Security offices. If you want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT: 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 XX
minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM
TO YOUR LOCAL SOCIAL SECURITY OFFICE. 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: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to
our time estimate to this address, not the completed form.
The amount of your SSI check is based on the information you tell us. To continue getting the right
Reporting
Responsibilities payment amount, you must report certain changes that happen to you. Changes could make your check bigger or
smaller.
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
sponsor's spouse if you are an alien. You must also report if any of these people buy or sell anything of value.
A List of Most of the Changes You Must Report Is On The Next Page.
How To
Report
Changes
You can report changes in any of the following ways:
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.
Form
• Call us, toll free, at 1-800-772-1213.
• Call your local Social Security Office at the number at the top of this form.
• By mail or in person -- see the address at the top of this form.
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.
SSA-8203-BK (8-2006)
EF (08-2006)
Page 9
CHANGES TO REPORT
WHERE YOU LIVE—You must report to Social Security if:
• You move.
• You leave the United States for 30 days or more.
• You are released from a hospital, nursing home, etc.
• You are no longer a legal resident of the United
States.
• You (or your spouse) leave your household for
a calendar month or longer. For example,
you enter a hospital or visit a relative.
HOW YOU LIVE—You must report to Social Security:
• If someone moves into or out of your household.
• If the amount of money you pay toward
household expenses changes.
• If your former spouse dies.
• Births and deaths of any people with whom you live.
• Changes in your marital status:
- You get married, separated, divorced, or
your marriage is annulled.
- You separate from your spouse or start
living together again after a separation.
- You begin living with someone as husband
and wife.
- Your spouse dies.
INCOME—You must report to Social Security if:
• The amount of money (or checks or any other
type of payment) you receive from someone or
someplace goes up or down or you start to
receive money (or checks or any other type of
payment).
• You start work or stop work.
• Your earnings go up or down.
• You become eligible for benefits other than SSI.
HELP YOU GET FROM OTHERS—You must report to Social Security if:
• The amount of help (money, food, clothing, or
payment of household expenses) you receive
goes up or down.
• Someone stops helping you.
• Someone starts helping you.
THINGS OF VALUE THAT YOU OWN—You must report to Social Security if:
• The value of your resources goes over $2,000
when you add them all together ($3,000 if you
are married and live with your spouse).
• You sell or give any things of value away.
• You buy or are given anything of value.
YOU ARE BLIND OR DISABLED—You must report to Social Security if:
• Your condition improves or your doctor says
you can return to work.
• You go to work.
YOU ARE UNMARRIED AND UNDER AGE 22—A report to Social Security must be made if:
• You are under age 18 and live with your
parent(s), ask your parents to report if they
have a change in income, a change in their
marriage, a change in the value of anything
they own, or either has a change in residence.
• 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.
• You get married.
• You start or stop school.
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.
Form
SSA-8203-BK (8-2006)
EF (08-2006)
Page 10
| File Type | application/pdf |
| File Title | Printing L:\MHFORMS\S8203.FRP |
| Author | 711857 |
| File Modified | 2006-08-10 |
| File Created | 2006-08-10 |