SSA-3988-OCR-SM-W-1(orginial)

Form Approved
OMB No. 0960-0643

Social Security Administration

STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR SUPPLEMENTAL
SECURITY INCOME PAYMENTS

RETURN THIS FORM WITHIN 30 DAYS FROM RECEIPT

PRINT ANSWERS LIKE THIS ►
PRINT DATES LIKE THIS ►

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2

3

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5

Month Day
0 6 / 0 1 / 2

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7

Year
0 0

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Yes

9
OR LIKE THIS ►

No
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6

If the mailing address shown above is not correct, provide the correct mailing address
(Number, Street, City, State, and Zip Code):

None-N/A

Street:

Apartment No.:

City:

State:

Zip Code:

YOUR SOCIAL SECURITY NUMBER (SSN):
SPOUSE’S NAME:
SOCIAL SECURITY NUMBER (SSN):
BECAUSE YOU ARE THE REPRESENTATIVE PAYEE, YOU MUST ANSWER THE FOLLOWING
QUESTIONS AS IF
WERE COMPLETING THE FORM.

1.

What is your current marital status?
Married living with Spouse

Married NOT living with Spouse

Divorced

Widowed

Form SSA-3988-OCR-SM-W (07-2006)

3988 1

Single
Question continues on the next page
3988

EW991A

Does this represent a change in your marital status since

?

Yes No

If the answer to the question is “no,” go to Question 2.
If the answer to the question is “yes,” please give the date that your marital status changed.
(Month/Year)

2.

/

a. Name:
Relationship:

None-N/A
Spouse

Date Moved In

Mother
/

Father

Child

Other Relative

Date Moved Out

/

b. Name:
Relationship:

Spouse

Mother
/

Father

/

Child

Date Moved In

Since

/

/

Other Relative

Other

/

Date Moved Out

c. Name:
Relationship:

Other

None-N/A

Date Moved In

3.

Yes No

Since
, has anyone moved into or out of your residence?
(include births and deaths) If the answer is “yes,” complete the information below:

/

None-N/A
Spouse

Mother
/

Father

/

Child

Other Relative
/

Date Moved Out

Other
/

Yes No

, have you lived at a different address?

If the answer to the question is “yes,” give the new address:
None-N/A

ADDRESS (Number, Street, City, State, and Zip Code):

Street:

City:
Date You Moved (Month/Year)

4.

Apartment No.

State:

Zip Code:

/

Does anyone live in the same household with you?

Yes No

If “yes,” list all the people who live in the same household with you.
Form SSA-3988-OCR-SM-W (07-2006)

3988 2

Question continues on the next page

None-N/A

a. Name:
Relationship:

Spouse

Date of Birth

Mother
/

Father

Child

Other Relative

Social Security
Number

/

-

Spouse

Date of Birth

Mother
/

Father

Child

Other Relative

Social Security
Number

/

-

c. Name:
Relationship:

Spouse

Mother
/

Father

Child

Other Relative

Social Security
Number

/

-

d. Name:
Spouse

Mother
/

Father

Child

Other Relative

Social Security
Number

/

-

Other
-

Other
-

None-N/A

e. Name:

Date of Birth

-

None-N/A

Date of Birth

Relationship:

Other

None-N/A

Date of Birth

Relationship:

-

None-N/A

b. Name:
Relationship:

Other

Spouse

Mother
/

/

Father

Child

Other Relative

Social Security
Number

-

Other
-

If you need more space use the REMARKS Section on page 11.

5.

Do all of the people who live with you receive public assistance payments?

Yes No

(For example: welfare, VA pension, general assistance, and SSI.)

6.

Since

, did anyone who was NOT LIVING WITH YOU:

Yes No

Give you a free place to live?
Help you pay the mortgage, rent, property insurance, property
taxes, and/or sewer charges?

Give you or help you pay for food, gas, electricity, heating
fuel, water, and/or garbage collection service?

Give you any other financial help?
If the answer to all 4 of the questions is “no,” go to Question 7.
If the answer to any of the 4 questions is “yes,” please explain assistance received:
Form SSA-3988-OCR-SM-W (07-2006)

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3988

EW991B

7.

Since
, have you or your spouse living with you been in a hospital, nursing
home, jail or prison, or other institution for a full calendar month or longer? (A “full calendar
month” means, for example, from December 1 through December 31.)

Yes No

If the answer to the question is “no,” go to Question 8.
If the answer to the question is “yes,” please give:
You

Your
Spouse

Date Entered
(Month/Day/Year)
a.

/

Hospital

Date Discharged
(Month/Day/Year)

/

/

a.

Nursing Home

Jail

/

Other Institution

None-N/A

Name and Address of Institution:

b.

/

Hospital

/

/

b.

Nursing Home

Jail

/

Other Institution

None-N/A

Name and Address of Institution:

c.

/

Hospital

/

/

c.

Nursing Home

Jail

/

Other Institution

None-N/A

Name and Address of Institution:

d.
Hospital

/

/

/

d.

Nursing Home

Jail

/

Other Institution

None-N/A

Name and Address of Institution:

8.

Since
, have you or your spouse living with you been outside the United States
(the 50 States, District of Columbia, and the Northern Mariana Islands) for more than 30 days in a
row?

Yes No

If the answer to the question is “no,” go to Question 9.
If the answer to the question is “yes,” please give:

Form SSA-3988-OCR-SM-W (07-2006)

3988 4

Question continues on the next page

You

Your
Spouse

Date(s) Left
(Month/Day/Year)

Date(s) Returned
(Month/Day/Year)

Where Did You OR
Your Spouse, Go?
N/A

a.

/

/

/

a.

/
N/A

b.

/

/

/

b.

/
N/A

c.

/

/

/

c.

/
N/A

d.

/

/

/

d.

/

Yes No
9.

Since

, have you or your spouse living with you worked?

Are you or your spouse living with you currently working?

Do you or your spouse living with you expect to work in the next 14 months?
If the answer to all 3 of the questions is “no,” go to question 10.
If the answer to any of the 3 questions is “yes,” please complete the following:
Example: If you have $600, it would be printed

You

Your
Spouse

Name of Employer/
Address

, 6

$

like this. SHOW DOLLARS ONLY

0

Gross Wages
(Before Any Deductions)
Amount: $
Paid:

,

,

,
Weekly

Biweekly

From:

/

/

To:

/

/

From:

/

/

To:

/

/

From:

/

/

To:

/

/

Monthly

Amount: $

Form SSA-3988-OCR-SM-W (07-2006)

.

Weekly

Biweekly

Paid:

.

Monthly

Amount: $
Paid:

Dates of Employment
(Month/Day/Year)

Weekly

Biweekly

0 .

.

Monthly
3988 5

Question continues on the next page
3988

EW991C

Yes No

Are you a student?
Birth Date:

10. Since

, have you or your spouse living with you been self-employed or do you or
your spouse living with you expect to be self-employed in the current taxable year?

Yes No

If the answer to the question is “no,” go to Question 11.
If the answer to the question is “yes,” please give:
N/A

N/A

You

Your Spouse

Type of Business
Total Gross Income for Last Year

$

,

.

$

,

.

Net Income for Last Year

$

,

.

$

,

.

Estimated Gross Income for this Year

$

,

.

$

,

.

Estimated Net Income for this Year

$

,

.

$

,

.

11. Since

, 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:

Yes No

A. Private pensions or annuities (other than Social Security, SSI, or food stamps)?
B. Unemployment or worker’s compensation?
C. Welfare or State and local assistance based on need?
D. Veterans Administration benefits (based on need, not based on need, education)?
E. Railroad Board, Black Lung, Military or Civil Service pensions?
F. Rental/lease income?
G. Alimony or child support?
H. Dividends or royalties?
I. Interest earned on money in bank accounts (including interest in checking account)?
J. Money from a trust fund?
Form SSA-3988-OCR-SM-W (07-2006)

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Question continues on the next page

K. Money from any other person or organization?
L. Any other income not included above?
If the answer to all 12 of the questions is “no,” go to Question 12.
If the answer to any of the questions is “yes,” tell us about that item. Please give:
Type of
Received by
Income
(choose from You Your
Spouse
letters above)

Amount/How Often

,

$
Weekly

Dates Received or Expected

.
Biweekly

From:

/

To:

/

From:

/

To:

/

From:

/

To:

/

From:

/

To:

/

From:

/

To:

/

Source
(Name/Address of
Person, Bank, Company
or Organization)
N/A

Monthly
,

$
Weekly

.
Biweekly

N/A

Monthly

,

$
Weekly

.
Biweekly

N/A

Monthly
,

$
Weekly

.
Biweekly

N/A

Monthly
,

$
Weekly

.
Biweekly

N/A

Monthly

12. Do you or your spouse living with you have your SSI check sent directly to a bank
or other financial institution? (This is known as “Direct Deposit”)

Form SSA-3988-OCR-SM-W (07-2006)

3988 7

You:

Your
Spouse:

Yes No

Yes No

13. 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 for any of these items:

Yes No

A. Cash (with you, at home, or in a safe deposit box)?
B. Checking or savings accounts?
C. Money market accounts?
D. Credit union accounts?
E. Christmas club accounts?
F. Savings certificates/certificates of deposit?
G. Promissory notes or IOU’s?
H. Stocks, bonds or U.S. Savings Bonds?
I. Trusts?
If the answer to all 9 of the questions is “no,” go to Question 14.
If the answer to any of the 9 questions is “yes,” please give:

Total Value of Each

Name and Address of Bank, Company or Organization

Other

Your Spouse

You

Owner or
Co-Owner
Name of
Each Item
(choose from
letters above)

N/A
$

,

.

Account Number:

N/A
$

,

.

Account Number:

N/A
$

,

.

Account Number:
Form SSA-3988-OCR-SM-W (07-2006)

3988 8

Total Value of Each

Name and Address of Bank, Company or Organization

Other

Your Spouse

You

Owner or
Co-Owner
Name of
Each Item
(choose from
letters above)

N/A
,

$

.

Account Number:

Yes No

14. Do you or your spouse living with you own, or partially 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, and life estates. Do not include the home you live in.)
If the answer to the question is “no,” go to Question 15.
If the answer to the question is “yes,” please give:

Estimated Current
Market Value

Other

Your Spouse

You

Owner or
Co-Owner
Tax Assessed Value,
if known

Amount or Mortgage
Payment, if any

Amount Owed on this
Property

$

,

. $

,

. $

,

. $

,

.

$

,

. $

,

. $

,

. $

,

.

Description (Include type and size of structures, acreage or lot size, and location of property)

N/A

Use (Describe how the property is used. If not in use, give date of last use and next planned use.)

N/A

Form SSA-3988-OCR-SM-W (07-2006)

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15. Since

, 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.)

You

Your
Spouse

Yes No Yes No

If the answer to the question is “no,” go to Question 16.
None-N/A

If the answer to the question is “yes,” please explain:

You

Your
Spouse

Yes No Yes No
16. a. Are you age 62 or older?
b. If you are age 50 or older, are you a widow(er)?
c. If you are age 50 or older and divorced, is your divorced spouse deceased?
d. If you were disabled before age 22, do you have a parent who is age 62 or older or
disabled, or deceased?

17. a. Which language do you prefer to use when speaking to us?
English

Spanish

Other (write in name of language):

b. Which language do you prefer that we use to write to you?
English

Spanish

Other (write in name of language):

WE ARE REQUIRED BY LAW TO ASK THE FOLLOWING QUESTIONS OF ALL SSI RECIPIENTS

18. a. Have you (or your spouse living with you) been convicted of, or charged with a
crime, or an attempt to commit a crime, which is a felony, or in jurisdictions that do not
define crimes as felonies, is punishable by death or imprisonment for a term exceeding 1
year regardless of the actual sentence imposed?
If “yes,” in which state did this occur?

Answer b.

b. Since
, has a warrant been issued for your (or your spouse living
with you) arrest because you (or your spouse living with you) were charged or convicted
of a crime that carries a sentence of over 1 year, or because you (or your spouse living
with you) violated a condition of your probation or parole under Federal or State law?
If “yes,” explain below (provide warrant information, if available):

Form SSA-3988-OCR-SM-W (07-2006)

3988 10

You

Your
Spouse

Yes No Yes No

You

Your
Spouse

Yes No Yes No
19. a. Have you (or your spouse living with you) been subject to a condition of parole or
probation under Federal or State law?
b. Since
, have you (or your spouse living with you) violated a
condition of your parole or probation?
If “yes,” explain below (provide warrant information, if available):

20. a. Since

, have you or your spouse living with you sold, transferred
title, disposed of or given away any property including property in foreign countries?
b. Since
given away any money?

Yes No

, have you or your spouse living with you disposed of or

If money was given away, please give amount:

$

,

.

Yes No
21. a. Have you used any medical care or services in the past 12 months that was paid for by
Medicaid (or Medi-Cal, etc.)?
b. Do you expect to receive any medical care or service in the next 12 months that will be
paid for by Medicaid (or Medi-Cal, etc.)?
c. Without Medicaid (or Medi-Cal, etc.), would you be unable to pay your medical bills
if you became ill or injured in the next 12 months?
REMARKS:

Form SSA-3988-OCR-SM-W (07-2006)

3988 11

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 know
that anyone who makes or causes to be made a false statement or representation of material fact in application or for use
in determining a right to payment under the Social Security Act commits a crime punishable under Federal or Sate law or
both. I affirm that all information I have given in this document is true.
SIGNATURES (Write in ink)
Your Signature (First name, middle initial, last name)
SIGN
HERE

/

DATE:

/

Area Code & Telephone Number (Where you can be reached)

(

)

None

-

Spouse’s Signature (First name, middle initial, last name) (Sign only if spouse is also receiving SSI payments)
SIGN
HERE

/

DATE:

/

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 and Zip Code)

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

REPRESENTATIVE PAYEE (Write in ink)
If you are the Representative Payee and are filing this statement on behalf of another person give:
Your Title or Relationship to the Recipient
Your Full Name (First name, middle initial, last name)
Address (Number, Street, City, State, and Zip Code)

Your Social Security Number
-

-

Area Code & Telephone Number (Where you can be reached)

(

)

None

-

FOR SSA USE ONLY
WBDOC

WBDOC1

Form SSA-3988-OCR-SM-W (07-2006)

WBDOC2

WBDOC3
3988 12

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FO1

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