Information Collection

SSA-8000-BK - Application for Supplemental Security Income

IC 44924 under ICR 200705-0960-014 · OMB 0960-0229.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0229 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8000-BK SSA-8000-BK - Application for Supplemental Security Income	Form
SSA-8000-BK Application for Supplemental Security Income Mock-up SSA-8000-BK.pdf	Form
original SSA-8000-BK.pdf Application for Supplemental Security Income	IC Document

IC Title:

SSA-8000-BK - Application for Supplemental Security Income

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.207 20 CFR 416.305-.335

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8000-BK	Application for Supplemental Security Income	Mock-up SSA-8000-BK.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 33,851

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	33,851	33,851
Annual IC Time Burden (Hours)	23,132	23,132
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application for Supplemental Security Income	original SSA-8000-BK.pdf	05/31/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.