Form SSA-8010-BK Statement of Income and Resources

Form Approved
OMB No. 0960-0124

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF INCOME AND RESOURCES

D.O. Use

Name of Applicant/Recipient

I am/We are providing this statement on behalf of
to determine his/her eligibility for Supplemental Security Income
and any federally administered State supplementation under title
XVI of the Social Security Act, for benefits under the other
programs administered by the Social Security Administration, and
where applicable, for medical assistance under title XIX of the
Social Security Act.

Social Security Number

/

/

Filing Date
MM
DD
YY
Date of Last Determination
MM
DD
YY

OR

PERSONS REPORTING INCOME AND/OR RESOURCES
First Name, Middle Initial, Last Name
Spouse's Name (First, middle initial, last)
Social Security Number

Social Security Number

/

/

Check Which:
Sponsor

/

/

Ineligible Child Check Which: (Spouse of)
Essential Person
Sponsor
Parent

Parent

1. PUBLIC INCOME MAINTENANCE PAYMENTS (Governmental

Assistance Based on Need)
(a) Have you received any of the public income maintenance
payments listed in (b) below since the first moment of the
filing date month or the last determination, or do you expect
to receive them in any of the next 14 months?

You
YES

Your Spouse
NO

YES

NO

Go to (b) Go to #3 Go to (b) Go to #3

(b)Give the following information about the payments:
TYPE

REC'D
BY

HOW
OFTEN

PERIOD
EXPECTED
COVERED
RECEIPT
BY INCOME
DATE*

AMOUNT

IDENTIFICATION
NUMBER

SOURCE

You
$
Social Security
Your Monthly
Administration
$
Spouse
>
State or Local GovYou
$
ernment Assistance Your
>
$
Based on Need
Spouse
>
Refugee Assistance
You
$
Payments Based on Your
>
$
Need
Spouse
>
$
Aid to Families with You
>
Dependent Children Your
$
Spouse
>
General Assistance
You
$
Bureau of Indian
from the Bureau of
>
Your
Affairs
$
Indian Affairs
Spouse
You
$
Disaster Relief
Your
$
Spouse
You
$
Dept. of
Veterans Benefits
Your
Based on Need
Veterans Affairs
$
Spouse
* If you are not receiving this income this month but expect it, enter the date you think you will receive it.
> If your share of the grant is unknown, enter the amount of the monthly family grant.
Supplemental
Security Income

2. OTHER INCOME YOU RECEIVED WHILE RECEIVING PUBLIC

INCOME MAINTENANCE PAYMENTS
(a) Have you received any other income in addition to any public
income maintenance payments shown in #1?
Form SSA-8010-BK (9-2004)
Destroy Prior Editions

EF (03-2006)

Page 1

You
YES

Your Spouse
NO

YES

NO

Go to (b) Go to #6 Go to (b) Go to #6

2. (b)
(Cont)

3.

If you are:
x The sponsor of an alien
x The spouse of a sponsor
x An essential person

Then:
Answer questions 3, 4 and 5 about your other income.

x A parent
x The spouse of a parent

If you have received these public income maintenance payments
continuously since the date shown on page 1 AND you expect to
continue receiving these payments this month and for the next 14
months, go to #6; OTHERWISE, go to #3.

x An ineligible child

If you have received and expect to continue receiving these
public income maintenance payments as described above,
go to #17; OTHERWISE, go to #3.

(a) Have you received wages since the first moment of
the filing date month or since the last
determination?

You
YES
Go to (b)

NO
Go to (d)

Your Spouse
YES
NO
Go to (b)

Go to (d)

(b)Name and Address of Employer (include telephone number and area code, if known)
You
Your Spouse

(c) Total wages received (before any deductions) for each month:
Month(s)
You
Amounts
Month(s)

Your
Spouse

Amounts

(d)Do you expect to receive any wages in the next
14 months?

You
YES
Go to (e)

NO
Go to #4

Your Spouse
YES
NO
Go to (e)

Go to #4

(e) Name and address of employer if different from 3(b) (include telephone number and area code, if known)
You
Your Spouse

(f) Give the following information:
RATE OF PAY

You

$

per

Your
Spouse $

per

AMOUNT WORKED PER
PAY PERIOD

(g)Do you expect any change in wage information
provided in 3(f)?
(h)Explain change:
You

Form SSA-8010-BK (9-2004)

HOW OFTEN
PAID

You
YES
Go to (h)

Your Spouse

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PAY DAY OR
DATE PAID

NO
Go to #4

DATE LAST PAID
(Month, day, year)

Your Spouse
YES
NO
Go to (h)

Go to #4

4. (a) Have you been self-employed at any time since the

You
YES

beginning of the taxable year in which the filing date
month or the last determination occurs or do you
expect to be self-employed in the current taxable year?
(b)Give the following information:
TYPE OF BUSINESS

GROSS
INCOME

LAST YEAR'S:
NET
INCOME
LOSS

Go to (b)

GROSS
INCOME

Your Spouse
YES
NO

NO
Go to #5

Go to (b)

THIS YEAR'S:
NET
INCOME
LOSS

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Go to #5

DATES OF SELFEMPLOYMENT

You

Your
Spouse

5. (a) Since the first moment of the filing date month or the last determination, have you received or do you expect to receive income
in the next 14 months from any of the following sources?

FEDERAL BENEFITS:
Social Security
Railroad Retirement
Veterans Affairs Benefits Not Based on Need
Office of Personnel Management (Civil Service)
Military Pension, Special Pay, or Allowance
Black Lung
Earned Income Tax Credits
STATE/LOCAL BENEFITS:
Unemployment Compensation
Worker's Compensation
State Disability
State or Local Pension
PRIVATE BENEFITS:
Employer or Union Pension
Insurance or Annuity Payments
Private Needs-Based Assistance
MISCELLANEOUS:
Interest (bank accounts, stocks, CD's, etc.)
Rental/Lease Income
Dividends/Royalties
Alimony/Cash Support
Child Support
OTHER INCOME NOT PREVIOUSLY MENTIONED:

Form SSA-8010-BK (9-2004)

EF (03-2006)

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You
YES

Your Spouse
NO

YES

NO

5. (b)Give the following information for any "Yes" answer in 5(a); otherwise go to #6.
(Cont)

PERSON
RECEIVING

TYPE OF
INCOME

AMOUNT

FREQUENCY

DATES EXPECTED
OR RECEIVED

SOURCE (Name/Address of Person,
Bank, Company, or Organization)

IDENTIFYING
NUMBER

From:

You

$

To:
From:

You

$

To:
From:

You

$

Your
Spouse
Your
Spouse
Your
Spouse
6.

To:
From:

$

To:
From:

$

To:
From:

$

To:

You
YES

RESOURCES
(a) Do you own or are you buying any real estate other
than the home in which you live?

Go to (b)

Your Spouse
YES
NO

NO
Go to #7

Go to (b)

Go to #7

(b)Give the following information:
DESCRIPTION OF PROPERTY (Include type and size of HOW IS IT USED? (If not used now, when was
structure, acreage or lot size, location.)
it last used and what is next planned use?)
Item 1

Item 1

Item 2

Item 2

ESTIMATED CURRENT
MARKET VALUE

OWNER'S NAME

TAX ASSESSED
VALUE

AMOUNT OF MORT- AMOUNT OWED
GAGE PAYMENT
ON ITEM

Item 1

$

$

$

$

Item 2

$

$

$

$

7. (a) Do you own or does your name appear on the title

of any vehicles; e.g., cars, trucks, boats,
motorcycles, etc.?
(b)
OWNER'S NAME

DESCRIPTION
(YEAR, MAKE & MODEL)

You
YES
Go to (b)

USED FOR

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Go to #8

Go to (b)

EQUIPPED FOR
HANDICAPPED?
YES

Form SSA-8010-BK (9-2004)

Your Spouse
YES
NO

NO

Go to #8

CURRENT
MARKET
VALUE

NO

AMOUNT
OWED

$

$

$

$

$

$

You
YES

8. (a) Do you own or are you buying any life insurance

policies?

Go to (b)

NO
Go to #9

Your Spouse
YES
NO
Go to (b)

Go to #9

(b)Give the following information on each policy:
OWNER'S NAME

NAME AND ADDRESS OF INSURANCE COMPANY

NAME OF INSURED

Policy (#1)
Policy (#2)
Policy (#3)
FACE
VALUE

POLICY NUMBER

CASH SURRENDER VALUE

LOANS AGAINST
YES
NO

DATE
PURCHASED

Policy

$

$

$

Policy (#2)

$

$

$

Policy

$

$

$

9. (a) Do you (either alone or jointly with any other

You

person) own any:

YES

Your Spouse
NO

YES

NO

Life estates or ownership interest in an unprobated estate?
Household or personal items worth more than $500 each?
Other equipment (business or non-business) or property
of any kind?

(b)Give the following information for any "Yes" answer in 9(a); otherwise go to #10.
OWNER'S NAME

NAME OF ITEM

VALUE

AMOUNT OWED
WHERE APPROPRIATE, GIVE NAME AND
ADDRESS OF BANK OR OTHER ORGANIZATION
ON ITEM

$

$

$

$

10. (a) Do you own or does your name appear (either alone or with
any other person's name) on any of the following items?

You
YES

Your Spouse
NO

YES

NO

Cash at home, with you, or anywhere else
Checking Accounts
Saving Accounts
Credit Union Accounts
Christmas Club Accounts
Certificates of Deposit
Notes
Stocks or Mutual Funds
Bonds
Other items that can be turned into cash
(b)Give the following information for any "Yes" answer in 10(a); otherwise go to #11.
OWNER'S NAME

Form SSA-8010-BK (9-2004)

NAME OF ITEM

EF (03-2006)

VALUE

NAME AND ADDRESS OF BANK OR
AMOUNT OWED
OTHER ORGANIZATION IF APPROPRIATE
ON ITEM

$

$

$

$

$

$

$

$
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11. (a) Do you have any assets set aside for burial expenses
such as burial contracts, trusts, agreements, or anything
else you intend for your burial expenses? Include any
assets mentioned in items #6 through #10 above.
DESCRIPTION (Where appropriate, give
name and address of organization and
account/policy number)

(b)

VALUE

Item 1

$

Item 2

$

FOR WHOSE BURIAL

You
YES
Go to (b)

NO

Go to #12

WHEN SET
ASIDE
(Month, Day, Year)

Your Spouse
YES
NO
Go to (b)

Go to #12

OWNER'S NAME

WILL INTEREST EARNED OR APPRECIATION IN
VALUE REMAIN IN THE BURIAL FUND?

IS ITEM IRREVOCABLE?

Item 1

YES

NO

YES Go to #12

NO Explain in (c)

Item 2

YES

NO

YES Go to #12

NO Explain in (c)

(c) Explanation:
Item 1
Item 2
12. (a) Do you own any cemetery lots, crypts, caskets,

vaults, urns, mausoleums or other repositories for
burial or any headstones or markers?
(b)

OWNER'S NAME

You
YES
Go to (b)

Go to #13

FOR WHOSE
BURIAL

DESCRIPTION

NO

Your Spouse
YES
NO
Go to (b)

Go to #13

CURRENT
RELATIONSHIP
TO YOU OR MARKET VALUE
YOUR SPOUSE (if applicable)

$
$
You
YES

13. (a) Are you the sponsor of an alien admitted for

permanent residence in the United States?

Go to (b)

NO

Go to #17

Your Spouse
YES
NO
Go to (b)

Go to #17

(b)If you are filing this report on behalf of the alien claimant/recipient, go to #14. If you are filing this
report on behalf of your child (or your spouse's child) who is applying for/eligible for SSI, go to #16.
You
YES

14.

(a) Do you have any dependents?

Go to (b)

NO

Go to #15

Your Spouse
YES
NO
Go to (b)

Go to #15

(b)Give the following information about your dependent(s):
RELATIONSHIP TO
YOU OR SPOUSE

NAME

Form SSA-8010-BK (9-2004)

EF (03-2006)

Page 6

FILING FOR/
RECEIVING SSI

15. A sponsor may be liable for any overpayments made

to an alien that result from the sponsor's failure to
provide correct information regarding deemable income
and resources. Do you agree to notify the Social
Security Administration immediately about any
changes in your income and resources and do you also
agree to report any change in your address?

You

Your

YES
Go to #17

NO
Explain in
Remarks
and go to
# 17.

Spouse

YES
Go to #17

NO
Explain in
Remarks
and go to
#17.

16. Give the following information about the alien(s) you sponsor:
NAME OF
ALIEN

SPONSOR
YOU
SPOUSE

SOCIAL
SECURITY NUMBER

/

/

/

/

/

/

/

/

/

/

DATE OF
ADMISSION

FILING FOR/
RECEIVING SSI

REMARKS - (You may use this space for any explanations. Enter the item number before each explanation. If you need more space, use a signed form SSA-795).

Form SSA-8010-BK (9-2004)

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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.
The Social Security Administration will check your statements and compare its records with
records from other State and Federal agencies, including the Internal Revenue Service, to make
sure the applicant/recipient is paid the correct amount.

SIGNATURES
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.
17. Your Signature (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)
Telephone number(s) at which you may be
contacted during the day

SIGN
HERE

(

)

-

area code

Spouse's Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE
NOTE:

If you are the representative payee and are filing this statement on behalf of another person (other
than your spouse), please print below your full name, followed by your title or relationship to the
person whose income and resources you are reporting (for example, "John J. Jones, Son").

Name (First, middle initial, last)

Title or Relationship

Your Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)

Zip Code

City and State

Enter name of county (if any)
in which you live

Your Residence Address (If different from your mailing address)
City and State

Zip Code

Enter name of county (if any)
in which you live

WITNESSES
Your statement does not normally 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 addresses.

1. Signature of Witness

2. Signature of Witness

Address (Number and street, city, state, and ZIP code) Address (Number and street, city, state, and ZIP code)

Form SSA-8010-BK (9-2004)

EF (03-2006)

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PAPERWORK/PRIVACY ACT NOTICE
The Social Security Administration is authorized to collect the information on this statement under
Sections 1614 and 1621 of the Social Security Act, as amended (42 U.S.C. 1382c(f) and 1383(3)).
The information is needed to enable Social Security to determine eligibility or continued eligibility of an
individual who is filing for or receiving monthly benefits. While it is VOLUNTARY for you to furnish the
information on this form to Social Security, failure to provide all or part of this information could prevent
an accurate and timely decision on this claim and could result in the loss of some benefits.
Although the information you furnish on the application is rarely used for any other purpose than stated
in the foregoing, there is a possibility that information may be disclosed to another person or to another
governmental agency as follows: (1) to enable a third party or an agency to assist Social Security in
establishing rights to Supplemental Security Income payments and (2) to comply with Federal laws
requiring the release of information from Social Security records (e.g., to the Dept. of Veterans Affairs).
We may also use the information you give us in computer matching programs even if you do not agree.
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.
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 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 26 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, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

NAME OF SSI CLAIMANT/RECIPIENT

SOCIAL SECURITY NUMBER

/

DATE

/

REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income check is based on the information told to us. You must tell Social
Security every time there is a change - while we process this application AND if the person named above starts
receiving Supplemental Security Income. So that the individual continues getting the right payment amount, you
must report certain changes that happen to you.
Remember a change may make the SSI monthly payment bigger or smaller. Report changes in your income and the
income of your husband/wife or a child who lives with you. You must also report changes in things of value that
you and your spouse own.
You must tell us about any change within 10 days after the month it happens. If you do not report changes, we
may have to take as much as $25, $50, or $100 out of future checks the individual is due.

HOW TO REPORT

You can make your reports by telephone at the telephone number shown
below or you may report in person or by mail at the address shown below.
See reverse side of this page for "Changes to Report."

Telephone Number (include area code) to call Social Security Office you may come in person or mail your request to:
if you have a question or something to report.

(

)

-

area code

Form SSA-8010-BK (9-2004)

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CHANGES TO REPORT
WHERE YOU LIVE - You must report to Social Security if:

x You move.

x You are no longer a legal resident of the
United States.

x 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:
x Someone moves into or out of your household.
x Your
x The amount of money you pay toward
household expenses changes.
-

marital status changes:
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.

x Births and deaths of any people with whom
you live.

INCOME - You must report to Social Security if:

x 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).

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

HELP YOU GET FROM OTHERS - You must report to Social Security if:

x The amount of help (money, food, clothing, or
payment of household expenses) you receive
goes up or down.

x Someone stops helping you.
x Someone starts helping you.

THINGS OF VALUE THAT YOU OWN - You must report to Social Security if:

x 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).

x You sell or give any things of value away.
x You buy or are given anything of value.

YOU ARE UNMARRIED AND UNDER AGE 21 - A report to Social Security must be made if:

x You start or stop school.

x Your income changes.

x You get married.

YOU ARE SELECTED AS A REPRESENTATIVE PAYEE - You must report to Social Security if:

x The person for whom you are filing this statement 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.)

x You will no longer be able or no longer wish to act as that person's representative payee.
Form SSA-8010-BK (9-2004)

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KEEP THIS PAGE FOR YOUR RECORDS