Form SSA-8150 Reporting Events - SSI

Form Approved
OMB No. 0960-0128

REPORTING EVENTS - SSI
USE THIS FORM ONLY WHEN THERE IS A CHANGE TO REPORT
PRINT NAME OF PERSON (OR COUPLE) THAT THIS REPORT IS ABOUT
NAME

SOCIAL SECURITY NUMBER

NAME

SOCIAL SECURITY NUMBER

DOES THIS PERSON(S) ALSO RECEIVE SOCIAL SECURITY
(GREEN) CHECKS?

(CHECK ONE)

YES

NO

NOTE: CHECK AND COMPLETE ONLY ITEMS THAT HAVE BEEN CHANGED SINCE YOU LAST
REPORTED TO SOCIAL SECURITY.
Check the blocks below to tell about changes for Yourself or Someone You Live With.
CHANGE OF ADDRESS (OR LIVING ARRANGEMENTS)
DATE OF CHANGE
Moved or changed address or will move soon.
(Print new address at bottom of form.) ............................................................... Date
Entered or left at an institution (such as a hospital, nursing home, jail or other
facility -- Print new address at bottom of form.) .................................................. Date
The number of people living in the same household as you has changed
(or will soon) ........................................................................................................ Date
Leaving the United States for 30 days or more. ................................................. Date
CHANGE IN INCOME

Have recently gotten a house, car, or other expensive item .............................. Date
No longer have a house, car, or other expensive item ....................................... Date
Name has been added to another person's bank account, stocks, or bonds ..... Date
CHANGES AFFECTING DISABLED OR BLIND RECIPIENTS
Disabled or blind - condition improved................................................................. Date
OTHER CHANGES
Marriage, separation, divorce, annulment ..........................................................
......................................................... Date
Under age 22 - change in school attendance ..................................................... Date
Death .................................................................................................................. Date
Fleeing prosecution, or to avoid custody, or confinement after conviction, a
crime, or an attempt to commit a crime, which is a felony. ................................. Date
Violating a condition of your parole or probation under Federal or State law. ... Date
REMEMBER TO REPORT CHANGES FOR BOTH YOURSELF AND ANYONE YOU LIVE WITH
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.
SIGN YOUR NAME

DATE SIGNED

NUMBER AND STREET APARTMENT NO. , P O BOX OR RURAL ROUTE (Print)
CITY AND STATE

ZIP CODE

COUNTY (If any)

TELEPHONE NUMBER (if any)

ALTHOUGH I LIVE AT THE ABOVE ADDRESS, I WANT CHECKS SENT TO:
NUMBER AND STREET APARTMENT NO. , P O BOX OR RURAL ROUTE
CITY AND STATE
Form SSA-8150-EV (9-2002) Destroy Prior Editions

ZIP CODE

FOLD THIS GUMMED FLAP

Change in earnings from work (or a job recently started or ended) ................... Date
Received increase or decrease in pension, veteran's check, unemployment,
railroad, or other payment .................................................................................... Date
Getting more or less other income (such as someone else paying your bills,
support payments, interest, dividends, gifts, inheritances, etc.) ......................... Date
CHANGE IN RESOURCES

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 complete this mailer unless we display a valid Office of
Management and Budget control number. We estimate that it will take 5 minutes to
complete this collection. Send only comments on our time estimate to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401.