Information Collection

Application for Supplemental Security Income

IC 188727 under ICR 200909-0960-004 · OMB 0960-0444.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0444 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8001-BK Application for Supplemental Security Income	Form
SSA-8001-BK Application For Supplemental Security Income SSA-8001 revised.pdf	Form
SSA-8001-BK - Marked Up Revised Copy.pdf SSA-8001-BK - Marked-Up Copy Showing Current Revisions	IC Document

IC Title:

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 416.305 - 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-8001-BK	Application For Supplemental Security Income	SSA-8001 revised.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: 19,351

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	19,351	19,351
Annual IC Time Burden (Hours)	5,805	5,805
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8001-BK - Marked-Up Copy Showing Current Revisions	SSA-8001-BK - Marked Up Revised Copy.pdf	09/17/2009

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