Form SSA-8006-F4 Statement of Living Arrangements, In-Kind Support and Ma

Form Approved
OMB No. 0960-0174

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF LIVING ARRANGEMENTS, IN-KIND SUPPORT AND MAINTENANCE
CLAIMANT'S/BENEFICIARY'SNAME (Print, first, middle initial, last)

CLAIMANT'S/RECIPIENT'S SOCIAL SECURITY
NUMBER

CLAIMANT'S/BENEFICIARY'S SPOUSE'S NAME (Print if spouse applying or receiving benefits)

SPOUSE'S SOCIAL SECURITY NUMBER

DATE OF CHANGE OF LIVING SITUATION (If applicable)

TYPE OF CHANGE (Change of residence, household composition,
contribution amount, etc.)

THIS SSA-8006-F4 COVERS THE PERIOD BEGINNING

THROUGH

PART I
Initial Claims: Complete Part I when a change in living arrangement occurs after claim is filed and claim is pending.
Posteligibility: Complete Part I when response(s) to questions on the SSA-8202 (short form Statement for Determining Continuing Eligibility for Supplemental Security Income Payments) require additional living arrangement
development.

1. CHECK THE BLOCKS WHICH BEST DESCRIBE YOUR LIVING ARRANGEMENTS
A. I live (with):
Alone

Eligible spouse

Ineligible spouse

Parent(s)

Child(ren)

Essential person

Other people

Sponsor

B. I live in a:
House
Room (private home)

Apartment

Room (Commercial establishment)

Mobile home

Other (specify)

C. Total number of people in household
(including yourself)

2. CHECK "YES" OR "NO" TO THE FOLLOWING QUESTIONS AND PROVIDE ADDITIONAL INFORMATION AS
REQUESTED.
A. Do you (and/or your spouse, or deemor) own or are you (and/or your
spouse, or deemor) buying the home you live in? If "yes", go to
question 3.

YES

NO

B. Do you (and/or your spouse, or deemor) rent the place where you
live? If "yes," go to D.

YES

NO

C. Does anyone who lives with you rent the place where you live?
If "no," go to question 3.

YES

NO

D. Are you or anyone you live with related to the landlord
(landlord's spouse)?

YES

NO

If "yes", indicate relationship
E. If you answered "yes" to B. or C., provide the following information:
LANDLORD'S NAME

LANDLORD'S PHONE NUMBER

Form SSA-8006-F4 (10-2006) EF (08-2008)

LANDLORD'S ADDRESS

DATE RENTAL AGREEMENT BEGAN
month
year

MONTHLY RENTAL AMOUNT

$

3. DOES ANY AGENCY, ORGANIZATION OR ANYONE WHO DOES NOT

LIVE WITH YOU PAY, OR HELP YOU PAY FOR ANY OF THE FOLLOWING
ITEMS:
FOOD, RENT, HOME MORTGAGE PAYMENTS, PROPERTY
INSURANCE (IF REQUIRED BY MORTGAGE HOLDER), REAL PROPERTY
TAXES, HEATING FUEL, GAS, ELECTRICITY, GARBAGE REMOVAL,
WATER AND/OR SEWER BILLS?

YES

NO

If "yes," please provide the following information about each item you receive, then go to question 4.
ITEM

FREQUENCY
NAME, ADDRESS AND TELEPHONE NUMBER OF CONTRIBUTOR
OF
ADDRESS
TELEPHONE NUMBER PAYMENT
NAME

4. IF YOU DO NOT LIVE WITH OTHERS, SKIP TO PART III. IF YOU LIVE

WITH OTHERS, DO ALL THE OTHER HOUSEHOLD MEMBERS RECEIVE
SOME TYPE OF PUBLIC PAYMENT BASED ON NEED (e.g., TANF, BIA,
SSI, VA)?

IN
CASH

YES

IN
KIND

DOLLAR
VALUE

NO

AGENCY NAME

IF "Yes," indicate from which agency, then go to Part III.
IF "No," go to Part II.

PART II
Complete Part II when individual lives with at least one person other than, or in addition to, spouse, child(ren), or
person whose income may be deemed to the individual.

1. CHECK "YES" OR "NO" TO THE FOLLOWING QUESTIONS OR PROVIDE THE INFORMATION REQUESTED.
A. Do you eat all your meals out?
If "Yes," go to C.
If "No," go to B.
B. Do you buy all your food separately from other household members?
C. How much is your average cash contribution per month toward the
household expenses listed in 4. below.

MONTHLY CASH CONTRIBUTIONS FROM OTHERS WITH WHOM YOU
LIVE:

NO

YES

NO

YES

NO

$

D. Do you have an agreement to pay back the people you live with for
your share of the household expenses?

2. IF YOU OR YOUR SPOUSE OWN OR RENT, SHOW THE TOTAL

YES

$

3. CHECK 'YES' OR 'NO' TO THE FOLLOWING QUESTIONS AND PROVIDE ADDITIONAL INFORMATION AS
REQUESTED ONLY IF YOU ANSWERED 'NO' TO BOTH QUESTIONS 1.A. AND 1.B. AND YOU DO NOT OWN OR
RENT THE PLACE WHERE YOU LIVE.
YES

A. Is part or all of the amount in question 1.C. just
for food?

HOW MUCH?

$

YES

B. Is part or all of the amount in question 1.C. just
for shelter?
Form SSA-8006-F4 (10-2006) EF (08-2008)

NO

HOW MUCH?

$
2

NO

4. WHAT IS THE AVERAGE MONTHLY AMOUNT OF THE FOLLOWING HOUSEHOLD CASH EXPENSES FOR THE
PERIODS INDICATED?

FROM

THROUGH

FROM

THROUGH

FROM

THROUGH

CASH EXPENSES

Food (Complete only if both 1.A. and 1.B.
above are answered "no")

$

$

$

$

$

$

Mortgage or rent
Property insurance (if required by
mortgageholder)
Real property taxes
Heating fuel
Electricity
Gas
Water
Sewer
Garbage removal
Total

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

COMPUTER MATCHING STATEMENT: 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 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 10 minutes to read the instructions, gather the
facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. Tofind the nearest office, call1-800-772-1213 (TTY 1-800-325-0778). Send only comments relating to our time estimate above
to: SSA, 6401- Security Blvd., Baltimore, MD 21235-6401.

See Revised Paperwork Reduction Act Statement

Form SSA-8006-F4 (10-2006) EF (08-2008)

3

PART III
YOUR RESPONSIBILITIES: Anyone who knowingly and willfully makes or causes to be made a false statement or
representation of material fact in an application or for use in determining a right to payment under the Social Security
Act commits a crime punishable under Federal or State law or both.
Do you understand that the information provided is subject to verification
and do you authorize sources to release to the Social Security Administration
information needed to verify your statements?

YES

NO

Do you understand that if there is any change in the information you have
provided on this statement that you must report it to the Social Security
Administration because your eligibility or benefit amount could be affected?

YES

NO

Do you understand that failure to report any change could result in a penalty
to you of $25 to $100 if the report is not made within 10 days after the end
of the month in which the change occurred?

YES

NO

Do you affirm that all the information you gave in this document or in
support of it is true?

YES

NO

COLLECTION AND USE OF INFORMATION FROM YOUR STATEMENT OF LIVING ARRANGEMENTS
PRIVACY ACT NOTICE
The Social Security Administration (SSA) is authorized to collect the information on this form under Sections 1631(e)
of the Social Security Act, as amended (42 U.S.C. 1383) (e)). While it is not mandatory for you to furnish the
information on this form to SSA, failure to provide all or part of the information could prevent an accurate and timely
decision on your claim and could result in the loss of some payments. 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.
Although the information you furnish on this form 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 another
governmental-agency as follows: (1) to enable a third party or an agency to assist SSA in establishing rights to
supplemental security income payments and (2) to comply with Federal laws requiring the release of information from
SSA records (e.g., to the Veterans Administration) and 3) to facilitate statistical research and audit activities
necessary to assure the integrity and improvement of the social programs (e.g., to the Bureau of the Census and
private concerns under contract of SSA). See Revised PA
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.

SIGNATURES
YOUR SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)(WRITE IN INK)

DATE (MONTH, DAY, YEAR)

SPOUSE'S SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)(WRITE IN INK)

TELEPHONE NUMBER(S) AT WHICH YOU MAY BE
CONTACTED DURING THE DAY (INCLUDE AREA CODE)

SIGN
HERE

SIGN
HERE
MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX OR RURAL ROUTE)

CITY AND STATE

ZIP CODE

ENTER NAME OF COUNTY (IF ANY)

NOTE: If residence address is different from mailing address, show in "Remarks".
This statement does not ordinarily 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 address.
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-8006-F4 (10-2006) EF (08-2008)

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The following revised Privacy Act Statement will be inserted into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to determine your living
arrangements.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent an accurate and timely decision on your claim, and
could result in the loss of some payments.
We rarely use the information you supply for any purpose other than for determining
your living arrangements. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 7
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING 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 (TTY 1-800-325-0778).
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.