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'S
RECIPIENT'S NAME (Print, first, middle initial, last)

CLAIMANT'S/RECIPIENT'S SOCIAL SECURITY
NUMBER

CLAIMANT'S/BENEFICIARY'S
RECIPIENT'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

Apartment

Room (Commercial establishment)

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

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

LANDLORD'S ADDRESS

DATE RENTAL AGREEMENT BEGAN
month
year

Form SSA-8006-F4 (03-2010) EF (03-2010) Destroy Prior Editions

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

YOU DO NOT LIVE WITH OTHERS, SKIP TO PART III. IF YOU LIVE
4. IF
WITH OTHERS, DO ALL THE OTHER HOUSEHOLD MEMBERS RECEIVE

IN
CASH

YES

SOME TYPE OF PUBLIC PAYMENT BASED ON NEED (e.g., TANF, BIA,
SSI, VA)?

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?
separately

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 (03-2010) EF (03-2010)

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 mortgage
holder)
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.

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.

Form SSA-8006-F4 (03-2010) EF (03-2010)

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

Privacy Act Statement
Collection and Use of Personal Information

See
Revised
Privacy
Act Attached
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.

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 (03-2010) EF (03-2010)

4

SSA will insert the following revised Privacy Act Statement 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.
We will use the information you provide to determine your living arrangements.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making 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. 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 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.
A complete list of routine uses for this information are available in Systems of Records Notices
entitled, Master Beneficiary Record, 60-0090, and Supplemental Security Income Record, 600103. These notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.