Form SSA-8000-BK Application for Supplemental Security Income (Revised)

Form Approved
OMB No. 0960-0229
Do Not Write in This Space
DATE STAMP

TEL

SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Note: Social Security Administration staff or others who help people apply for
SSI will fill out this form for you.

I am/We are applying 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.

Filing Date (Month, Day, Year)

Receipt

Protective

FS-REFERRED

FS-SSA/APP
Preferred Language
Written:
Spoken:

TYPE OF CLAIM

Individual with
Ineligible Spouse

Individual

Couple

Child

Child with Parents

PART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment of
the filing date month.
1. (a) First Name, Middle Initial, Last Name

Sex

Birthdate

(month, day, year)

Male

Social Security Number

Female
(b) Did you ever use any other names (including
maiden name) or any other Social Security Numbers?
(c) Other Name(s)

YES Go to (c)

NO Go to (d)

Other Social Security Number(s) Used

(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:
Mother's
Maiden Name:

Father's
Name:

2. (a) Are you married?
(b) Date of marriage:

Go to #2

YES Go to (b)

NO Go to #3

(month, day, year)

(c) Spouse's Name (First, middle initial, last)

Birthdate

(month, day, year)

(d) Did your spouse ever use any other names
(including maiden name) or Social Security Numbers?
(e) Other Name(s)

YES Go to (e)

NO Go to (f)

Other Social Security Number(s) Used

(f) Are you and your spouse living together?
(g) Date you began living apart :

Social Security Number

(month, day, year)

FORM SSA-8000-BK (11/2007) Destroy Prior Editions Page 1

YES Go to #3

NO Go to (g)

(h) Address of spouse or name of someone who knows where spouse is. (Complete only if spouse is age 65,
2. blind or disabled.)

3.

You

(a) Have you had any other marriages?
If never married, check this box

Your Spouse, if filing

YES
NO
YES
NO
Go to (b)
Go to #4
Go to (b)
Go to #4
(b) Give the following information about your former spouse. If there was more than one former marriage,
show the remaining information in Remarks and go to #4.
YOU

YOUR SPOUSE

FORMER SPOUSE'S NAME
(including maiden name)
BIRTHDATE
(month, day, year)
SOCIAL SECURITY
NUMBER
DATE OF MARRIAGE
(month, day, year)
DATE MARRIAGE ENDED
(month, day, year)
HOW MARRIAGE ENDED

4.

If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
Your Spouse

You

(a) Are you unable to work because of illnesses,
injuries or conditions?

YES
Go to (b)

NO
Go to #5

YES
Go to (b)

(month, day, year)

NO
Go to #5

(month, day, year)

(b) Enter the date you became unable to work.
(c) What are your illnesses, injuries or conditions?
You

Your Spouse
Go to (d)

Go to (d)

(d) If you were unable to work because of illnesses, injuries, or conditions before you were age 22, do you
have a parent who is age 62 or older, unable to work because of illnesses, injuries or conditions, or deceased?
YES

Parent's Name:
Social Security Number:
Address:

NO

Go to #5
(month, day, year)

(e) When did the child become disabled?

Go to (f)

(f) What are the child's disabling illnesses, injuries or conditions?

Go to (g)
FORM SSA-8000-BK (11/2007)

Page 2

(g) Does the child have a parent(s) who is age 62 or older, unable to work because of illness, injuries, or
4. conditions, or deceased?
YES Parent's Name:
Social Security Number:
Address:

NO

Go to #5

5. Birthplace

City

State

Country (if other than the U.S.)

You
Your Spouse,
if filing

Go to #6

You
NO
Go to #7

Your Spouse, if filing
YES
NO
Go to #12
Go to #7

YES
Go to #12

NO
Go to #8

YES
Go to #12

NO
Go to #8

YES
Go to (b)

NO
Go to (c)

YES
Go to (b)

NO
Go to (c)

6. Are you a United States citizen by birth?

YES
Go to #12

7. Are you a naturalized United States citizen?
8. (a) Are you an American Indian born outside the
United States?

(b) Check the block that shows your American Indian status.
You
American Indian born in Canada

Your Spouse, if filing
Go to #12

American Indian born in Canada

Go to #12

Member of a Federally recognized Indian Tribe;

Member of a Federally recognized Indian Tribe;

Name of Tribe

Name of Tribe

Go to #12

Other American Indian
Explain in Remarks, then Go to (c)

Go to #12

Other American Indian
Explain in Remarks, then Go to (c)

(c) Check the block below that shows your current immigration status
You

Your Spouse, if filing

Amerasian Immigrant

Go to #9

Amerasian Immigrant

Go to #9

Lawful Permanent Resident

Go to #9

Lawful Permanent Resident

Go to #9

Refugee
Date of entry:

Go to #11

Refugee
Date of entry:

Go to #11

Asylee
Date status granted:

Go to #11

Asylee
Date status granted:

Go to #11

Conditional Entrant
Date status granted:

Go to #11

Conditional Entrant
Date status granted:

Go to #11

Parolee for One Year

Go to #11

Parolee for One Year

Go to #11

Cuban/Haitian Entrant

Go to #11

Cuban/Haitian Entrant

Go to #11

Deportation/Removal Withheld
Date:

Go to #11

Deportation/Removal Withheld
Date:

Go to #11

Other
Explain in Remarks, then Go to (d)
FORM SSA-8000-BK (11/2007)

Other
Explain in Remarks, then Go to (d)
Page 3

8. (d) If you have status, or have applied for status as the spouse, child, or parent of a child of a US citizen, or
lawfully admitted permanent resident alien, Go to #10; otherwise Go to #12.
9. If you are lawfully admitted for permanent residence:
Your Spouse

You

(month, day, year)

(a) Date of Admission
(b) Was your entry into the United States sponsored
by any person or promoted by an institution or group?

YES
Go to (c)

NO
Go to (d)

(month, day, year)

YES
Go to (c)

NO
Go to (d)

(c) Give the following information about the person, institution, or group, then Go to (d):
Name

Address

Telephone Number

(
(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?

You

Status:

To:
(e) If filing as an adult, did your parents ever work in
the United States before you were age 18?

(month, day, year)

From:
To:

YES
Go to (f)

-

Your Spouse, if filing
Status:

(month, day, year)

From:

)

NO
Go to #11

Go to (e)

YES
Go to (f)

NO
Go to #11

(f) Name and Social Security Number of parent(s) who worked.
Name

Social Security Number

Name

Social Security Number

10. (a) Have you, your child or your parent, been
subjected to battery or extreme cruelty while in the
United States?
(b) Have you, your child, or your parent filed a
petition with the Department of Homeland Security
for a change in immigration status because of being
subjected to battery or extreme cruelty?
11. Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the
United States?

YES
Go to (b)

NO
Go to #12

Your Spouse, if filing
YES
NO
Go to (b)
Go to #12

YES
Go to #11

NO
Go to #12

YES
Go to #11

NO
Go to #12

YES

NO

YES

NO

You

Explain in
#57(b), then
Go to #12

Go to #12

YES
Go to (c)

NO
Go to #13

(month, day, year)

12. (a) When did you first make your home in the United
States?
(b) Have you lived outside of the United States since
then?

Explain in
#57(b), then
Go to #12

Go to #12

YES
Go to (c)

NO
Go to #13

(month, day, year)

(month, day, year)

(c) Give the dates of residence outside the United
States.
13. (a) Have you been outside the United States (the 50
states, District of Columbia and Northern Mariana
Islands) 30 consecutive days prior to the filing date?
FORM SSA-8000-BK (11/2007)

(month, day, year)

From:

From:

To:

To:

YES
Go to (b)

Page 4

NO
Go to #14

YES
Go to (b)

NO
Go to #14

13. (b) Give the date (month, day, year) you left the
United States and the date you returned to the
United States.

Date Left:

Date Left:

Date Returned:

Date Returned:

IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #14.
IF YOU ARE MARRIED AND YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY INCOME AND
YOU LIVED TOGETHER AT ANY TIME SINCE THE FIRST MOMENT OF THE FILING DATE MONTH, GO TO
#14; OTHERWISE GO TO #15.
14. (a) Is your spouse/parent the sponsor of an alien who
YES Go to (b)
No Go to #15
is eligible for supplemental security income?
(b) Eligible Alien's Name

Eligible Alien's Social Security Number
Go To #15

15. (a) Do you have any unsatisfied felony warrants for
your arrest?

NO
Go to #16

Your Spouse, if filing
YES
NO
Go to (b)
Go to #16

Name of State/Country

Name of State/Country

You
YES
Go to (b)

(b) In which state or country was this warrant issued?

Go to (c)

Go to (c)
(c) Was the warrant satisfied?

YES
Go to (d)

(d) Date warrant satisfied

NO
Go to #16

month, date, year

YES
Go to (b)

(b) In which state or country was the warrant issued?

NO
Go to #16

month, date, year

You

16. (a) Do you have any unsatisfied Federal or State
warrants for violating the conditions of probation or
parole?

YES
Go to (d)

NO
Go to #17

Name of State/Country

Your Spouse, if filing
YES
NO
Go to (b)
Go to #17
Name of State/Country

Go to (c)
(c) Was the warrant satisfied?

YES
Go to (d)

(d) Date warrant satisfied

Go to (c)

NO

YES

NO

Go to #17

Go to (d)

Go to #17

month, day, year

month, day, year

PART II - LIVING ARRANGEMENTS - The questions in this section refer to the signature date.
17. Check the block which best describes your present living situation:
Household
Non-Institutional Care
Institution
Transient
FORM SSA-8000-BK (11/2007)

Since (month, day, year)
Since (month, day, year)
Since (month, day, year)
Since (month, day, year)
Page 5

Go to #22
Go to #20
Go to #18
Go to #35

INSTITUTION
18. Check the block that identifies the type of institution where you currently reside, then Go to #19:
School

Rehabilitation Center

Hospital

Jail

Rest or Retirement Home

Other (Specify)

Nursing Home
19. Give the following information about the INSTITUTION:
(a) Name of institution:

(b) Date of admission:

(c) Date you expect to be released from this institution:

Go to #35
NON-INSTITUTIONAL CARE
20. Check the block that best describes your current residence, then Go to #21:
Foster Home

Group Home

Other (Specify)

21. Give the following information about your Noninstitutional Care:
(a) Name of facility where you live:
(b) Name of placing agency

Address

Telephone Number

(

)

-

(c) Does this agency pay for your room and board?
YES Go to #35

NO If NO, who pays?

Go to #35

HOUSEHOLD ARRANGEMENTS
22. Check the block that describes your current residence, then Go to #23:
House

Mobile Home

Apartment

Houseboat

Room (private home)

Other (Specify)

Room (commercial establishment)
23. Do you live alone or only with your spouse?
FORM SSA-8000-BK (11/2007)

YES Go to #25
Page 6

NO Go to #24

24. (a) Give the following information about everyone who lives with you:
Public
Assistance
Name

Relationship

YES

NO

Sex
M F

Blind or
Disabled

If Under 22
Married Student Social Security
Birthdate
mm/dd/yy YES NO YES NO YES NO
Number

If anyone listed is under age 22 and not married, Go to (b); otherwise, Go to #25.
(b) Does anyone listed in 24(a) who is under age 18, OR
between ages 18-22 and a student, receive income?
(c) Child Receiving Income

YES Go to (c)
Source and Type

NO Go to #25
Monthly Amount

$
$
$
$
$
$
25. (a) Do you (or does anyone who lives with you) own
or rent the place where you live?
FORM SSA-8000-BK (11/2007)

Page 7

YES Go to #26

No Go to (b)

25.

(b) Name of person who owns or
rents the place where you live

Address

Telephone Number

(

)

-

(c) If you live alone or only with your spouse, and do not own or rent, Go to #35; otherwise, Go to #29.
26. (a) Are you (or your living with spouse) buying or do
you own the place where you live?

YES
Go to (c)

(b) Are your parent(s) buying or do they own the place
where you live?

YES Go to (c)

No
If you are a child living
with your parent(s) Go
to (b); otherwise Go to
#27
NO Go to #27

(c) What is the amount and frequency of the mortgage payment?
Amount:

$

Frequency of Payment:

Go to (d)

(d) If you are a child living only with your parents, or only with your parents and their other children who are
subject to deeming, or with others in a public assistance household, or living alone or with your spouse,
Go to #35; otherwise Go to #29.
27. (a) Do you (or your living with spouse) have rental
liability for the place where you live?

YES Go to (d)

(b) Does your parent(s) have rental liability?

YES Go to (d)

NO
If you are a child living
with your parent(s) Go
to (b); otherwise Go to
NO Go to (c)

(c) Does anyone who lives with you have rental liability for the place where you live?
YES Give name of person with rental liability:

Go to #28

NO Give name of person with home ownership:

Go to #29

(d) What is the amount and frequency of the rent payment?
Amount:

$

Frequency of Payment:
Go to #28

28. (a) Are you (or anyone who lives with you) the parent
or child of the landlord or the landlord's spouse?
(b) Name of person related to landlord
or landlord's spouse

Relationship

YES Go to (b)

NO Go to (c)

Name and address of landlord (include telephone
number and area code, if known):

(c) If you are a child living only with your parents, or only with your parents and their other children who are
subject to deeming, or with others in a public assistance household, or living alone or with your spouse,
Go to #35.
29. (a) Does anyone living with you contribute to the
household expenses? (NOTE: See list of household
expenses in #34)
(b) Amount others contribute:
FORM SSA-8000-BK (11/2007)

YES Go to (b)

NO Go to #30

$
Page 8

Go to #30

30. (a) Do you eat all your meals out?
(b) Do you buy all your food separately from other
household members:

YES Go to #31

NO Go to (b)

YES Go to #31

NO Go to #31

31. Do you contribute to household expenses?
YES Average Monthly Amount:

$

Go to #32

NO Go to #32
32. (a) Do you have a loan agreement with anyone to repay
the value of your share of the household expenses?

YES Go to (b)

NO Go to #32(d)

(b) Give the name, address and telephone number of the person with whom you have a loan agreement :

(c) Will the amount of this loan cover your share of the
household expenses?

YES Go to #35

NO Go to (d)

(d) If you contribute toward household expenses and you answered "NO" to both 30(a) & (b), Go To #33. If
you answered "YES" to either 30(a) or 30(b), Go to #34.
If you do not contribute toward household expenses, go to #35.
33. (a) Is part or all of the amount in #31 just for food?
YES Give Amount:

$

Go to (b)

NO Go to (b)

Go to #34

NO Go to #34

(b) Is part or all of the amount in #31 just for shelter?
YES Give Amount:

$

34. What is the average monthly amount of the following household expenses:
(Show average over the past 12 months unless you have been residing at your present address less than 12
months. If so, show average for the months you have resided at your present address.)
CASH EXPENSES

AVERAGE MONTHLY AMOUNT

Food (complete only if #30(a) & (b) are answered NO)

$

Mortgage or Rent

$

Property Insurance (if required by mortgage lender)

$

Real Property Taxes

$

Electricity

$

Heating Fuel

$

Gas

$

Sewer

$

Garbage Removal

$

Water

$

TOTAL

$

FORM SSA-8000-BK (11/2007)

Page 9

Go to #35

35. (a) Does anyone who does NOT LIVE with you pay for, or provide you or your household (if applicable), any of
your food or shelter items?
YES Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NO

Go to (b)

(b) Does anyone who does NOT LIVE with you give you, or your household (if applicable), money to pay for
any of your or your household's food or shelter items?
YES Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NO
36. (a) Has the information given in #17-35 been the same
since the first moment of the filing date month?

Go to #36
NO
Explain in Remarks,
then Go to (b)

YES Go to (b)

(b) Do you expect any of this information to change?

YES
Explain in Remarks,
then Go to #37

NO Go to #37

PART III-RESOURCES-The questions in this section pertain to the first moment of the filing date
month.
37. (a) Do you own or does your name appear on, either
alone or with other people, the title of any vehicles
(auto, truck, motorcycle, camper, boat, etc.)?

(b) Owner's Name

You
YES
Go to (b)

Description (Year, Make &
Model)

38. (a) Do you own or are you buying any life insurance
policies?
FORM SSA-8000-BK (11/2007)

Your Spouse

NO
Go to #38

Used For

You
YES
Go to (b)

Page 10

NO
Go to #39

YES
Go to (b)

NO
Go to #38

Current
Market
Value

Amount
Owed

$

$

$

$

$

$

$

$
Your Spouse
YES
Go to (b)

NO
Go to #39

38.

(b)

Owner's Name

Name of Insured

Name & Address of
Insurance Company

Policy Number

Policy (#1)
Policy (#2)
Policy (#3)

Dividends
Face Value

Cash Surrender Value

Policy (#1) $

$

Policy (#2) $

$

Policy (#3) $

$

Date of Purchase

YES

NO

Accumulations
YES

NO

YES

(c) Loans Against Policy?

NO

Policy Number:
Amount:

$

Go to #39
You

39. (a) Do you (either alone or jointly with any other
person) own any:

YES

Your Spouse
NO

YES

NO

Life estates or ownership interest in an unprobated
estate?
Items acquired or held for their value as an
investment?
(b) Give the following information for any "Yes" answer in #39(a); otherwise, Go to #40.
Owner's Name

Name of Item

FORM SSA-8000-BK (11/2007)

Value

Amount Owed

$

$

$

$

$

$

$

$
Page 11

Give Name & Address of Bank or
Other Organization

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

You
YES

Your Spouse
NO

YES

NO

-Cash at home, with you, or anywhere else
-Financial Institution Accounts
Checking
Savings
Credit Union
Christmas Club
Time Deposits/Certificates of Deposit
Individual Indian Money Account
-Other (Including IRAs and Keough Accounts)
(b) If all the items in #40(a) are answered "NO", Go to #41. For any "YES" answer, give the following
information:

Owner's/Trustee's
Name

Name of Item

Name & Address of Bank or Other
Organization

Value

Identifying
Number

$

$

$
41. (a) Do you give us permission to obtain any financial
records from any financial institution?

YES
Go to (b)

(b) Do you own or does your name appear on any of
the following items:
-Stocks or Mutual Funds
-Bonds (Including U.S. Savings Bonds)
-Promissory Notes
-Trusts
-Other items that can be turned into cash
FORM SSA-8000-BK (11/2007)

Your Spouse, if filing

You

Page 12

NO
Go to (b)

NO
Go to (b)

Your Spouse

You
YES

YES
Go to (b)

NO

YES

NO

41. (c) If all the items in #41(b) are answered "NO", Go to #42. For any "YES" answer, give the following
information:
Owner's/Trustee's
Name

Name of Item

Name & Address of Bank or Other
Organization

Value

Identifying
Number

$

$
$
$
42. (a) Do you have any land, houses, buildings, real
property, property in a foreign country, equipment,
mineral rights, items in a safe deposit box, assets set
aside for emergencies or for your heirs, or any other
property of any kind that has not been shown
anywhere else on the application?

Your Spouse

You
YES
Go to (b)

NO
Go to #43

YES
Go to (b)

NO
Go to #43

(b) Describe the property (including size, location, and how it is used. If not used now, when was it last used
and what is next planned use.)
Item #1

Item #2

Owner's Name

Estimated Current
Market Value

Mortgage

Tax Assessed Value

Owed on Item

$

$

$

$

$

$

$

$

$

$

$

$

FORM SSA-8000-BK (11/2007)

Page 13

43. (a) Have you or your spouse acquired any assets since
the first moment of the filing date month?

YES Go to (b)

NO Go to (c)

YES Go to (d)

NO Go to #44

(b) Explain:

(c) Has there been any increase or decrease in the
value of you or your spouse's resources since the first
moment of the filing date month?
(d) Explain:

44. (a) Have you or your spouse sold, transferred title,
disposed of or given away, any money or other
property, (including money or property in foreign
countries), since the first moment of the filing date
month or within the 36 months prior to the filing date
month?
(b) If you co-owned any money or property with
another person(s), did you or any co-owner sell,
transfer, or give away any co-owned money or
property within the 36 months prior to the filing date
month?

Your Spouse

You
YES

NO

YES

Go to (b)
YES

NO

Go to (b)

NO

YES

NO

IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #45.
(c)
ITEM #1

OWNER'S/CO-OWNERS NAME

DESCRIPTION OF PROPERTY

DATE OF DISPOSAL

NAME AND ADDRESS OR
PURCHASER OR RECIPIENT

RELATIONSHIP TO OWNER

VALUE OF PROPERTY AND/OR
AMOUNT OF CASH GIFT

ITEM #2
ITEM #3

ITEM #1

$

ITEM #2

$

ITEM #3

$
SALES PRICE OR OTHER
CONSIDERATION

ARE OTHER CONSIDERATION OR DO YOU STILL OWN PART OF THE
PROCEEDS EXPECTED? EXPLAIN. PROPERTY?

SOLD ON OPEN MARKET?

GIVEN AWAY?

ITEM #1
ITEM #2
ITEM #3
TRADED FOR GOODS/SERVICES?

ITEM #1

YES

NO

YES

NO

YES

NO

ITEM #2

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES
ITEM #3
FORM SSA-8000-BK (11/2007)

NO

Page 14

45. (a) Do you have any assets set aside for burial
expenses such as burial contracts, trusts, agreements,
YES
or anything else you intend for your burial expenses?
Go to (b)
Include any items mentioned in #38 and #40-44.
(b) DESCRIPTION (Where appropriate, give
name & address of organization and account/
policy number.)

NO
Go to #46
WHEN SET
ASIDE

VALUE

Your Spouse

You

YES
Go to (b)

NO
Go to #46

OWNER'S NAME

(month, day, year)

Item 1

$
Item 2

$
FOR WHOSE BURIAL

IS ITEM IRREVOCABLE?

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

Item 1

YES

NO

YES Go to #46
Go to #46

Item 1

YES

NO

YES
Go to #46

NO
Explain in (c)
NO
Explain in (c)

(c) EXPLANATION

46. (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

Description

You
YES
Go to (b)

For Whose Burial

NO
Go to #47

Your Spouse
YES
NO
Go to (b)
Go to #47

Relationship to You
Current Market Value
or Your Spouse

$
$
$
FORM SSA-8000-BK (11/2007)

Page 15

Go to #47

PART IV -- INCOME
47. (a) Since the first moment of the filing date month, have you (or your spouse)
received or do you (or your spouse) expect to receive income in the next 14
months from any of the following sources?
State or Local Assistance Based on Need
Refugee Cash Assistance
Temporary Assistance for Needy Families
General Assistance from the Bureau of Indian Affairs
Disaster Relief
Veteran Benefits Based on Need (Paid Directly or Indirectly as a Dependent)
Veteran Payments Not Based on Need (Paid Directly or Indirectly as a
Dependent)
Other Income Based on Need
Social Security
Black Lung
Railroad Retirement Board Benefits
Office of Personnel Management (Civil Service)
Pension (Military, State, Local, Private, Union, Retirement or Disability)
Military Special Pay or Allowance
Unemployment Compensation
Workers' Compensation
State Disability
Insurance or Annuity Payments
Dividends/Royalties
Rental/Lease Income Not from a Trade or Business
Alimony
Child Support
Other Bureau of Indian Affairs Income
Gambling/Lottery Winnings
Other Income or Support
FORM SSA-8000-BK (11/2007)

Page 16

You
YES

Your Spouse
NO

YES

NO

47. (b) Give the following information for any block checked YES in #47(a); otherwise, Go to #48
Person
Receiving
Income

Type of
Income

Amount
Received

Source (Name,
Address of Person,
Frequency of Date Expected
Bank,
Payment
or Received
Organization, or

Identifying
Number

$
$
$
IF YOU EVER RECEIVED SSI BEFORE, GO TO #48; OTHERWISE GO TO #49
48. Are any overpayments being collected from benefits
you receive from the Social Security Administration,
Railroad Retirement Board, Office of Personnel
Management, Veterans' Affairs, Military Pensions,
Military Special Pay Allowances, Black Lung, Workers'
Compensation, or State Disability or Unemployment
Benefits?
49. Since the first moment of the filing date month, have
you received or do you expect to receive any meals or
other gifts which are not cash?
50. (a) Have you (or your spouse) received wages or sick
pay since the first moment of the filing date month
through the current month?

Your Spouse

You
YES
Explain in
Remarks,
then Go to
#49

NO
Go to #49

YES
Explain in
Remarks,
then Go to
#49

NO
Go to #49

YES
NO
Explain in
Go to #50
Remarks,
then Go to #50

YES
NO
Explain in
Go to #50
Remarks,
then Go to #50

YES
Go to (b)

YES
Go to (b)

NO
Go to (e)

NO
Go to (e)

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

Your Spouse

Go to (c)
Date last worked
(month, day, year)

(c)

Go to (c)

Date last paid
(month, day, year)

Date next paid
(month, day, year)

Your Amount

Your Spouse's Amount

$

$

You
Your
Spouse
(d) Total monthly wages received (before any
deductions)

(e) Do you (or your spouse) expect to receive any
wages in the next 14 months?

You
YES
Go to (f)

NO
Go to #51

Your Spouse
YES
NO
Go to (f)
Go to #51

(f) Name and address of employer if different from #50(b) (include telephone number, if known)
You

FORM SSA-8000-BK (11/2007)

Your Spouse

Page 17

50. (g) Give the following information:
RATE OF PAY

You

$

Your
Spouse

$

AMOUNT WORKED
PER PAY PERIOD

(h) Do you expect any change in wage information
provided in #50(g)

HOW OFTEN
PAID

PAY DAY OR
DATE PAID

You
YES
Go to (i)

NO
Go to #51

DATE LAST PAID
(month, day, year)

Your Spouse
YES
NO
Go to (i)
Go to #51

(i) Explain Change:
You

Your Spouse

51. (a) Have you been self-employed at any time since the
YES
beginning of the taxable year in which the filing date
Go to (b)
month occurs or do you expect to be self-employed in
the current taxable year?

You

Your Spouse

NO
Go to #52

YES
Go to (b)

NO
Go to #52

(b) Give the following information; then Go to #52
Date(s) Self-Employed

Date(s) Self-Employed

Type of Business

Type of Business

52. If you or your spouse are blind or disabled, do you
have any special expenses that you paid which are
necessary for you to work?

53.

Last Year's:
Gross Income

Last Year's:
Net Profit

Last Year's:
Net Loss

$

$

$

This Year's:
Gross Income

This Year's:
Net Profit

This Year's:
Net Loss

$

$

$

You
YES
Explain in
Remarks;
then Go to
#53

(a) Does your spouse/parent who lives with you have
to pay court-ordered support?

YES Go to (b)
Amount:

(b) Give amount and frequency of court-ordered
support payment.

NO
Go to #53

Your Spouse
YES
NO
Explain in
Go to #53
Remarks;
then Go to
#53
NO Go to NOTE
Frequency:

$
Go to (c)
Name:

Address:

(c) Give the following information about the person
who receives these payments:
NOTE: IF YOU ARE FILING AS A CHILD AND YOU ARE EMPLOYED OR AGE 18 - 22 (WHETHER EMPLOYED
OR NOT), GO TO #54; OTHERWISE, GO TO #55.
FORM SSA-8000-BK (11/2007)

Page 18

54. (a) Have you attended school regularly since the filing
date month?

YES Go to (d)

NO Go to (b)

(b) Have you been out of school for more than 4
calendar months?

YES Go to (c)

NO Go to (c)

(c) Do you plan to attend school regularly during the
next 4 months?
Name of School

YES Explain absence
in Remarks and Go to (d)

NO Go to #55

Name of School Contact

Dates of Attendance
From
To

Phone Number

Hours Attending or
Planning to Attend

Course of Study

PART V - POTENTIAL ELIGIBILITY FOR FOOD STAMPS/MEDICAL ASSISTANCE/OTHER
BENEFITS - If a California resident, Skip to #56
55.

You

(a) Are you currently receiving food stamps?

YES
Go to (b)

NO
Go to (c)

Your Spouse, if filing
YES
NO
Go to (b)
Go to (c)

(b) Have you received a recertification notice within
the past 30 days?

YES
Go to (e)

NO
Go to #56

YES
Go to (e)

NO
Go to #56

(c) Have you filed for food stamps in the last 60 days?

YES
Go to (d)

NO
Go to (e)

YES
Go to (d)

NO
Go to (e)

(d) Have you received an unfavorable decision?

YES
Go to (e)

NO
Go to #56

YES
Go to (e)

NO
Go to #56

(e) If everyone in the household receives or is applying for SSI, Go to (f); otherwise Go to #56.
(f) May I take your food stamp application today?

YES
Go to #56

YES
NO
Explain in (g) Go to #56

NO
Explain in (g)

(g) Explanation:

56. You may be eligible for Medicaid. However, you must help your State identify other sources that pay for
medical care. Also, you must give information to help the State get medical support for any child(ren) who is
your legal responsibility. This includes information to help the State determine who a child's father is. If you
want Medicaid, you must agree to allow your State to seek payments from sources, such as insurance
companies, that are available to pay for your medical care. This includes payments for medical care for you or
any person who receives Medicaid and is your legal responsibility. The State cannot provide you Medicaid if
you do not agree to this Medicaid requirement. If you need further information, you may contact your
Medicaid Agency.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to (b).
You
(a) Do you agree to assign your rights (or the rights of
anyone for whom you can legally assign rights) to
payments for medical support and other medical care
to the State Medicaid agency?
(b) Do you, your spouse, parent or stepparent have
any private, group, or governmental health insurance
that pays the cost of your medical care? (Do not
include Medicare or Medicaid.)

YES
Go to (b)

NO
Go to #57

YES
Go to (c)

(c) Do you have any unpaid medical expenses for the
3 months prior to the filing date month?

YES
Go to #57

FORM SSA-8000-BK (11/2007)

Page 19

Your Spouse, if filing
YES
Go to (b)

NO
Go to #57

NO
Go to (c)

YES
Go to (c)

NO
Go to (c)

NO
Go to #57

YES
Go to #57

NO
Go to #57

57. (a) Have you ever worked under the U.S. Social
Security System?

YES Go to (b)

(b) Have you, your spouse, or a former spouse (or
parent if you are filing as a child) ever:

You
Yes

No

NO Go to (b)
Your
Spouse/Parent
Yes
No

Filed for Benefits
Yes
No

Worked for a railroad
Been in military service
Worked for the Federal Government
Worked for a State or Local Government
Worked for an employer with a pension plan
Belonged to union with a pension plan
Worked under a Social Security system or pension
plan of a country other than the United States?
(c) Explain and include dates for any "Yes" answer given in #11 or #57(a); otherwise Go to #58.
You:
Your Spouse, if filing/Your Parent, if filing as a child:

PART VI -- MISCELLANEOUS -- (Answer #58 ONLY IF YOU ARE APPLYING ON BEHALF OF SOMEONE
ELSE: OTHERWISE GO TO #59.
58. (a) Name of Person/Agency Requesting
Benefits.

Relationship to Claimant

(b) If SSA determines that the claimant needs help
managing benefits, do you wish to be selected
representative payee?

YES

Your Social Security Number
(or EIN)

NO
(Explain in Remarks)

PART VII -- 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-8000-BK (11/2007)

Page 20

PART VIII -- IMPORTANT INFORMATION AND SIGNATURES
59. 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 you are paid the
correct amount.
We have asked you for permission to obtain, from any financial institution, any financial record about you
that is held by the institution. We will ask financial institutions for this information whenever we think
it is needed to decide if you are eligible or if you continue to be eligible for SSI benefits. Once authorized,
our permission to contact financial institutions remains in effect until one of the following occurs: (1) you or
your spouse notify us in writing that you are canceling your permission, (2) your application for SSI is denied
in a final decision, (3) your eligibility for SSI terminates, or (4) we no longer consider your spouse's income
and resources to be available to you. If you or your spouse do not give or cancel your permission you may
not be eligible for SSI and we may deny your claim or stop your payments.
60. 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 false information, or causes someone else to do so, commits a crime and may
be sent to prison, or may face other penalties, or both.
Your Signature (First name, middle initial, last name) (Sign in ink.) Date (month, day, year)
Telephone Number(s) where we can contact you
during the day:

SIGN
HERE

(

)

-

Spouse's Signature (Sign only if applying for payments.) (First name, middle initial, last name) (Sign in ink.)

SIGN
HERE
61. Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)
City and State

ZIP Code

County

62. Claimant's Residence Address (If different from applicant's mailing address)
City and State

ZIP Code

County

63. FOR
DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)
OFFICIAL
Routing Transit Number C/S Number
Depositor Account
No Account
USE
ONLY
Direct Deposit
Refused
64. If you are blind or visually impaired, check the type of mail you want to receive from us.
Certified

Regular

Regular with a Follow-up phone call

65.

WITNESS
Your application 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-8000-BK (11/2007)

Page 21

RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOME
Name

Social Security Number

Date

Name

Social Security Number

Date

If you have a question or something to report call:

(

)

Social Security Office you may visit or mail your request to:

-

For general information about Social Security, visit our website at www.socialsecurity.gov on the Internet.
We will process your application for Supplemental Security Income as quickly as possible. If you have trouble
getting any information or records we have asked for, please contact us and we will help you.
You should hear from us within _____ days after you have given us all the information we requested. Some claims
may take longer if additional information is needed. If you do not get a check or notice of determination within that
time, please get in touch with us.

See Revised Privacy Act Statement

PAPERWORK/PRIVACY ACT NOTICE

Section 1631(e) of the Social Security Act authorizes the collection of information requested on this form. The
information you provide will be used to enable the Social Security Administration to determine if you are eligible for
Supplemental Security Income payments. You do not have to give us the information requested. However, if you
do not provide the information, we will be unable to make an accurate and timely decision on your claim which may
result in loss of some payments. We may provide information collected on this form to another Federal, State, or
local government agency to assist us in determining your eligibility for SSI payments or if a Federal law requires the
release of information.
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 and financial institutions. 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 40
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.
REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income (SSI) check is based on the information told to us. You must tell
Social Security every time there is a change-while we process your application AND if you start receiving SSI.
Remember, a change may make the SSI monthly payment bigger or smaller. Report changes in income of your
ineligible husband/wife or child who lives with you or your sponsor or sponsor's spouse, if you are an alien. You
must also report changes in the things of value that these people own. You must also report changes in income,
school attendance and marital status of ineligible children who live with you.
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.
HOW TO REPORT
You may make your reports:
• By telephone at the telephone number shown above or call us toll free at 1-800-772-1213 or
• In person or
• By mail at the address shown above.
FORM SSA-8000-BK (11/2007)

Page 22

CHANGES TO REPORT
WHERE YOU LIVE --You must report to Social Security if:
• You move.
• You leave the United States for 30 consecutive days.
• You (or your spouse) leave your household for a
calendar month or longer. (For example, you enter a • You are no longer a legal resident of the United
States
hospital or visit a relative.)
• You are admitted to (for a calendar month or longer),
or released from, a hospital or nursing home, jail,
prison, or other correctional facility or other
institution.
HOW YOU LIVE -You must report to Social Security:
• If anyone moves into or out of your household.
• Your marital status changes:
• If the amount of money you pay toward household
--You get married, separated, divorced, or your
expenses changes.
marriage is annulled.
• Births and deaths of any people with whom you live.
--You begin living with someone as husband and
• Your spouse or former spouse dies.
wife.
INCOME-You must report to Social Security if you, your spouse/your parent(s):
• Start to receive money (or checks or any other type • Start work or stop work.
of payment) from someone or someplace.
• Earn more or less money. (Keep all paystubs and
• Have a change in the amount of money you receive.
provide them to SSA when requested.)
• Begin to receive child support payments or those
• Become eligible for benefits other than SSI.
payments go up or down.
• Win money from gambling or a lottery.
HELP YOU GET FROM OTHERS -You must report to Social Security if:
• The amount of help (money or food, or payment of
household expenses) you receive goes up or down.

• Someone stops helping you.
• Someone starts helping you.

THINGS OF VALUE THAT YOU OWN -You must report to Social Security if:
• The value of things that you own goes over $2000
when you add them all together ($3000 if you are
married and live with your spouse).

• You sell or give any thing of value away.
• You buy or are given anything of value.

YOU ARE BLIND OR DISABLED-You must report to Social Security if:
• Your condition improves or your doctor says you
can return to work.

• You go to work.

IF YOU ARE UNDER AGE 18 AND YOU ARE LIVING WITH YOUR PARENTS-A report to Social Security must be
made if:
• Your parents have a change in income, a change in their marriage, a change in the value of anything they
own, or either has a change in residence.
YOU ARE UNMARRIED AND UNDER AGE 22 - A report to Social Security must be made if:
• You start or stop school

• You get married or divorced

• You start or stop working

YOUR IMMIGRATION STATUS CHANGES• You must report any changes to Social Security.
YOU ARE SELECTED AS A REPRESENTATIVE PAYEE -You must report to Social Security if:
• The person for whom you receive SSI checks has
• You will no longer be able or no longer wish to act as
any changes listed above. (You may be held liable
that person's representative payee.
if you do not report changes that could affect the
SSI recipient's payment amount, and he/she is
overpaid.)
IF A WARRANT HAS BEEN ISSUED FOR YOUR ARREST -You must report to Social Security if:
• Your warrant is for a crime or an attempted crime
• Your warrant is for a violation of probation
that is a felony (or, in jurisdictions that do not define
or parole under Federal or State law.
crimes as felonies, a crime that is punishable by death
or imprisonment for a term exceeding 1 year); or
FORM SSA-8000-BK (11/2007)

Page 23

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 enable the Social Security
Administration to determine if you are eligible for Supplemental Security Income (SSI)
payments.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may keep us from making an accurate and timely decision on your
claim, which in turn may result in loss of some payments.
We rarely use the information you supply for any purpose other than for determining
eligibility for SSI. 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 and audit activities necessary to assure the
integrity and improvement of Social Security programs (e.g., to the Bureau of
the Census and private concerns under contract to Social Security).
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.
Complete lists of routine uses for this information are available in System of Records
Notice 60-0103, Supplemental Security Income Record and Special Veterans Benefits,
and also in System of Records Notice 60-0089, Claims Folder Systems. The Notices,

additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.ssa.gov or at your local Social Security office.