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

Individual with
Ineligible Spouse

Child

Couple

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

Birthdate

Sex
Male

(month, day, year)

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:

Go to #2

2. Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)

City and State

ZIP Code

County

3. Claimant's Residence Address (If different from applicant's mailing address)

City and State
4.

ZIP Code

County

DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)
Routing Transit Number

Form SSA-8000-BK (01-2012)
Destroy Prior Editions

Account Number

Checking

Enroll in Direct Express

Savings

Direct Deposit Refused

Page 1

5. (a) Are you married?

(b) Date of marriage:

YES Go to (b)

NO Go to #6

(month, day, year)

Birthdate

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

(month, day, year)

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

Social Security Number

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 :

YES Go to #6

NO Go to (g)

(month, day, year)

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

You

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

YES
Go to (b)

Your Spouse, if filing

NO
Go to #7

YES
Go to (b)

NO
Go to #7

(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

7. If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
(a) Are you unable to work because of illnesses,
injuries or conditions?

You

YES
Go to (b)

Your Spouse

NO
Go to #8

YES
Go to (b)

(month, day, year)

NO
Go to #7

(month, day, year)

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

Form SSA-8000-BK (01-2012)

Your Spouse
Go to (d)
Page 2

Go to (d)

7. (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 #8
(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)
(g) Does the child have a parent(s) who is age 62 or older, unable to work because of illness, injuries, or
conditions, or deceased?
YES

Parent's Name:
Social Security Number:
Address:

NO
8.

Birthplace

Go to #8
City

State

Country (if other than the U.S.)

You
Your Spouse,
if filing
YES
Go to #15

NO
Go to #10

Go to #9
Your Spouse, if filing
YES
NO
Go to #15
Go to #10

YES
Go to #15

NO
Go to #11

YES
Go to #15

NO
Go to #11

YES
Go to (b)

NO
Go to (c)

YES
Go to (b)

NO
Go to (c)

You

9. Are you a United States citizen by birth?
10. Are you a naturalized United States citizen?
11. (a) Are you an American Indian born outside the
United States?

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

Your Spouse, if filing

American Indian born in Canada

Go to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe

Go to #15

Other American Indian
Explain in Remarks, then Go to (c)
Form SSA-8000-BK 01-2012)

American Indian born in Canada

Go to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe
Other American Indian
Explain in Remarks, then Go to (c)

Page 3

Go to #15

11.

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

You
Amerasian Immigrant
Lawful Permanent Resident

Your Spouse, if filing
Amerasian Immigrant

Go to #12

Go to #12

Lawful Permanent Resident

Go to #12

Go to #12

Refugee
Date of entry:

Go to #14

Refugee
Date of entry:

Go to #14

Asylee
Date status granted:

Go to #14

Asylee
Date status granted:

Go to #14

Go to #14

Conditional Entrant
Date status granted:

Go to #14

Conditional Entrant
Date status granted:
Parolee for One Year
Cuban/Haitian Entrant
Deportation/Removal Withheld
Date:

Parolee for One Year

Go to #14

Go to #14

Cuban/Haitian Entrant

Go to #14

Go to #14

Deportation/Removal Withheld
Date:

Go to #14

Go to #14

Other
Explain in Remarks, then Go to (d)

Other
Explain in Remarks, then Go to (d)

(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 #13; otherwise Go to #15.
12. If you are lawfully admitted for permanent residence:
You

Your Spouse

(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

)

Your Spouse, if filing

Status:

Status:

(month, day, year)

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

From:

To:

To:
NO
Go to #14

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

Social Security Number

Name

Social Security Number

Form SSA-8000-BK (01-2012)

(month, day, year)

From:

YES
Go to (f)

Page 4

-

YES
Go to (f)

Go to (e)
NO
Go to #14

13.

You

(a) Have you, your child or your parent, been
subjected to battery or extreme cruelty while in the
United States?

YES
Go to (b)

(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?
14.

Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the
United States?

Your Spouse, if filing
YES
NO

NO
Go to #15

Go to (b)

YES

NO

YES

NO

Go to #14

Go to #15

Go to #14

Go to #15

YES

NO

Explain in
#60(b), then
Go to #15

Go to #15

YES
Explain in
#60(b), then
Go to #15

(month, day, year)

15. (a) When did you first make your home in the United
States?

YES

(b) Have you lived outside of the United States since
then?

Go to #16

YES
Go to (c)

From:

From:

To:

To:
YES

NO

Go to (b)

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

Go to #17

Go to #15

NO
Go to #16

(month, day, year)

(month, day, year)

16. (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?

NO

(month, day, year)

NO

Go to (c)

(c) Give the dates of residence outside the United
States.

Go to #15

YES
Go to (b)

Date Left:

Date Left:

Date Returned:

Date Returned:

NO
Go to #17

IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #17.
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
#17; OTHERWISE GO TO #18.
17. (a) Is your spouse/parent the sponsor of an alien who
YES Go to (b)
No Go to #18
is eligible for supplemental security income?
(b) Eligible Alien's Name

Eligible Alien's Social Security Number

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

You
YES

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

NO

Go to (b)
Go to #19
Name of State/Country

Go to #18
Your Spouse, if filing
YES
NO
Go to (b)
Go to #19
Name of State/Country

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

YES

NO

Go to (d)
(d) Date warrant satisfied

19. (a) Do you have any unsatisfied Federal or State
warrants for violating the conditions of probation or
parole?
Form SSA-8000-BK (01-2012)

YES
Go to (d)

NO
Go to #19

(month, day, year)

(month, day, year)

You

Your Spouse, if filing
NO
YES
Go to #20
Go to (b)

YES
Go to (b)
Page 5

Go to #19

Go to (c)

NO
Go to #20

19.

Name of State/Country

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

(c) Was the warrant satisfied?

YES
Go to (d)

Go to (c)
NO

YES

Go to #20

Go to (d)

(month, day, year)

(d) Date warrant satisfied

Name of State/Country
Go to (c)
NO
Go to #20

(month, day, year)

PART II - LIVING ARRANGEMENTS - The questions in this section refer to the signature date.
20.

Check the block which best describes your present living situation:
Since (month, day, year)

Household

Go to #25
Since (month, day, year)

Non-Institutional Care

Go to #23
Since (month, day, year)

Institution

Go to #21
Since (month, day, year)

Transient or homeless

Go to #38
INSTITUTION

21. Check the block that identifies the type of institution where you currently reside, then Go to #22:
School

Rehabilitation Center

Hospital

Jail

Rest or Retirement Home

Other (Specify)

Nursing Home
22. 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 #38
NON-INSTITUTIONAL CARE
23. Check the block that best describes your current residence, then Go to #24:
Foster Home

Group Home

Other (Specify)

24. Give the following information about your Noninstitutional Care:
(a) Name of facility where you live:
Form SSA-8000-BK (01-2012)

Page 6

24. (b) Name of placing agency

Address

Telephone Number

(

)

-

(c) Does this agency pay for your room and board?
YES Go to #38

NO If NO, who pays?

Go to #38

HOUSEHOLD ARRANGEMENTS
25. Check the block that describes your current residence, then Go to #26:
House

Mobile Home

Apartment

Houseboat

Room (private home)

Other (Specify)

Room (commercial establishment)
26. Do you live alone or only with your spouse?

YES Go to #28

NO Go to #27

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

Relationship

YES

NO

Sex
M F

Blind or
Disabled

Birthdate
Married Student
mm/dd/yy YES NO YES NO YES NO

If anyone listed is under age 22 and not married, Go to (b); otherwise, Go to #28.
Form SSA-8000-BK (01-2012)

If Under 22

Page 7

Social Security
Number

27.

(b) Does anyone listed in 27(a) who is under age 18, OR
between ages 18-22 and a student, receive income?
(c) Child Receiving Income

YES

NO

Go to (c)

Go to #28

Source and Type

Monthly Amount

$
$
$
$
$
$
28. (a) Do you (or does anyone who lives with you) own
or rent the place where you live?

YES Go to #29

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

No Go to (b)

Address

Telephone Number

(

)

-

(c) If you live alone or only with your spouse, and do not own or rent, Go to #38; otherwise, Go to #32.
29. (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 #30
NO Go to #30

(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 #38; otherwise Go to #32.
30. (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?
Form SSA-8000-BK (01-2012)

YES Go to (d)
Page 8

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

30. (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 #31

NO Give name of person with home ownership:

Go to #32

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

$

Frequency of Payment:
Go to #31

31. (a) Are you (or anyone who lives with you) the parent
or child of the landlord or the landlord's spouse?
Relationship

(b) Name of person related to landlord
or landlord's spouse

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 #38.
32. (a) Does anyone living with you contribute to the
household expenses? (NOTE: See list of household
expenses in #37)
(b) Amount others contribute:

YES Go to (b)

NO
Go to #33

$
Go to #33

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

YES Go to #34

NO Go to (b)

YES Go to #34

NO Go to #34

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

$

Go to #35

NO Go to #35
35. (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 #35(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 #38

NO Go to (d)

(d) If you contribute toward household expenses and you answered "NO" to both 33(a) & (b), Go To #36. If
you answered "YES" to either 33(a) or 33(b), Go to #37.
If you do not contribute toward household expenses, go to #38.
36. (a) Is part or all of the amount in #34 just for food?
YES Give Amount:

$

Go to (b)

NO Go to (b)

Go to #37

NO Go to #37

(b) Is part or all of the amount in #34 just for shelter?
YES Give Amount:

Form SSA-8000-BK (01-2012)

$
Page 9

37. 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 #33(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

$
$
$
$
$
$
$
$
$
$
$

Go to #38

38. (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

Go to #39

39. (a) Has the information given in #20-38 been the same
since the first moment of the filing date month?

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

YES Go to (b)

NO
Explain in Remarks,
then Go to (b)

YES
Explain in Remarks,
then Go to #40

NO Go to #40

PART III - RESOURCES - The questions in this section pertain to the first moment of the filing
date month.
40. (a) Do you own, or does your name appear (alone or
with any other person's name) on the title of any
vehicles (auto, truck, motorcycle, camper, boat, etc.)?
Form SSA-8000-BK (01-2012)

You
YES

Go to (b)
Page 10

NO
Go to #41

Your Spouse
YES
NO
Go to (b)

Go to #41

40.
(b) Owner's Name

Description
(Year, Make & Model)

You

41. (a) Do you own or are you buying any life insurance
policies?

YES

NO

Go to (b)
(b)

Owner's Name

Current
Market
Value

Used For

Go to #42

$

$

$

$

$

$

$

$

Your Spouse
YES
NO
Go to (b)

Name & Address of
Insurance Company

Name of Insured

Amount
Owed

Go to #42

Policy Number

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

Dividends
Cash Surrender Value

Face Value
Policy (#1)

$

$

Policy (#2)

$

$

Policy (#3)

$

$

(c) Loans Against Policy?

Date of Purchase

YES

NO

Accumulations
YES

YES

NO

NO

Policy Number:
Amount:

$

Go to #42
You

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

YES

Life estates or ownership interest in an unprobated
estate?
Items acquired or held for their value as an
investment?
Form SSA-8000-BK (01-2012)

Page 11

Your Spouse
NO

YES

NO

42. (b) Give the following information for any "Yes" answer in #42(a); otherwise, Go to #43.
Owner's Name

Name of Item

Value

Amount Owed

$

$

$

$

$

$

$

$

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

Give Name & Address of Bank or
Other Organization

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 #43(a) are answered "NO", Go to #44. For any "YES" answer, give the following
information:
Owner's/Trustee's
Name

Name of Item

Value

Name & Address of Bank or Other
Organization

$
$
$
Form SSA-8000-BK (01-2012)

Page 12

Identifying
Number

You

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

YES

NO

Go to (b)
(b) Do you own or does your name appear on any of
the following items:

Your Spouse, if filing

Go to (b)

Go to (b)

NO
Go to (b)

Your Spouse

You
NO

YES

YES

YES

NO

Stocks or Mutual Funds
Bonds (Including U.S. Savings Bonds)
Promissory Notes
Trusts
Other items that can be turned into cash
(c) If all the items in #44(b) are answered "NO", Go to #45. For any "YES" answer, give the following
information:

Owner's/Trustee's
Name

Name of Item

Value

Name & Address of Bank or Other
Organization

Identifying
Number

$

$
$
$
45. (a) Do you own, or does your name appear (alone or
with any other person's name) on any land, houses,
buildings, real property, property in foreign country,
equipment, mineral rights, items in a safe deposit box,
assets set aside for emergencies or heirs, or any other
property of any kind that has not been shown
anywhere else on the application

You
YES
Go to (b)

Your Spouse
NO

YES

NO

Go to #46

Go to (b)

Go to #46

(b) Describe the property (including size, location, and how it is used. If the property is not used now, when
was it last used? Do you plan to use the property in the future?
Item #1

Item #2

Form SSA-8000-BK (01-2012)

Page 13

45.

Estimated Current
Market Value

Owner's Name

Mortgage

Tax Assessed Value

Owed on Item

$

$

$

$

$

$

$

$

$

$

$

$

46. (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 #47

(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:

47. (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?

You
YES

Your Spouse
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 #48.
(c)

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 #1
ITEM #2
ITEM #3

$

ITEM #1
Form SSA-8000-BK (01-2012)

Page 14

47.

ITEM #2

$

ITEM #3

$
ARE OTHER CONSIDERATION OR
PROCEEDS EXPECTED? EXPLAIN.

SALES PRICE OR OTHER
CONSIDERATION

DO YOU STILL OWN PART OF THE
PROPERTY?

ITEM #1
ITEM #2
ITEM #3
SOLD ON OPEN MARKET?

GIVEN AWAY?

TRADED FOR GOODS/SERVICES?

ITEM #1

YES

NO

YES

NO

YES

NO

ITEM #2

YES

NO

YES

NO

YES

NO

ITEM #3

YES

NO

YES

NO

48. (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 items mentioned in #41 and #43-47.
(b) DESCRIPTION (Where appropriate, give
name & address of organization and account/
policy number.)
Item 1

YES

You
YES
Go to (b)

NO

YES

NO

Go to #49

Go to (b)

Go to #49

WHEN SET
ASIDE

VALUE

NO

Your Spouse

OWNER'S NAME

(month, day, year)

$

Item 2

$
FOR WHOSE BURIAL

Item 1

IS ITEM IRREVOCABLE?
YES

NO

WILL INTEREST EARNED OR APPRECIATION
IN VALUE REMAIN IN THE BURIAL FUND?
YES Go to #49

NO
Explain in (c)

Item 1

YES

NO

YES
Go to #49

(c) EXPLANATION

Form SSA-8000-BK (01-2012)

Page 15

NO
Explain in (c)

You

49. (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

YES
Go to (b)

For Whose Burial

Your Spouse
YES
NO

NO
Go to #50

Go to (b)

Go to #50

Relationship to You Current Market Value
or Your Spouse

$
$

$
Go to #50

PART IV -- INCOME
50. (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 (Foreign Military, State, Local, Private, Union, Retirement or
Disability)
Military Special Pay or Allowance
Unemployment Compensation
Form SSA-8000-BK (01-2012)

Page 16

You
YES

Your Spouse
NO

YES

NO

50.

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
(b) Give the following information for any block checked YES in #50(a); otherwise, Go to #51
Person
Receiving
Income

Type of Income

Amount
Received

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

Identifying
Number

$
$
$
IF YOU EVER RECEIVED SSI BEFORE, GO TO #51; OTHERWISE GO TO #52
51. 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?

You
YES
Explain in
Remarks,
then Go to
#52

Your Spouse
NO

YES

Go to #52 Explain in
Remarks,
then Go to
#52

NO
Go to #52

52. Since the first moment of the filing date month, have
YES
NO
YES
NO
you received or do you expect to receive any meals or Explain in
Go to #53 Explain in
Go to #53
other gifts which are not cash?
Remarks, then
Remarks, then
Go to #53
Go to #53
53. (a) Have you (or your spouse) received wages or sick
YES
NO
YES
NO
pay since the first moment of the filing date month
through the current month?
Go to (b)
Go to (e)
Go to (b)
Go to (e)
(b) Name and Address of Employer (include telephone number and area code, if known)
You

Your Spouse

Go to (c)
Form SSA-8000-BK (01-2012)

Page 17

Go to (c)

53. (c)

Date last worked
(month, day, year)

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)

$

$

You

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

YES

Your Spouse
YES
NO

NO

Go to (f)

Go to #54

Go to #54

Go to (f)

(f) Name and address of employer if different from #53(b) (include telephone number, if known)
You

Your Spouse

(g) Give the following information:
RATE OF PAY

You

$

Your
Spouse

$

AMOUNT WORKED
PER PAY PERIOD

HOW OFTEN
PAID

PAY DAY OR
DATE PAID

You

(h) Do you expect any change in wage information
provided in #53(g)

DATE LAST PAID
(month, day, year)

NO
Go to #54

Your Spouse
YES
NO
Go to (i)
Go to #54

NO
Go to #55

YES
Go to (b)

YES
Go to (i)

(i) Explain Change:
You

Your Spouse

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

YES
Go to (b)

You

Your Spouse

NO
Go to #55

(b) Give the following information; then Go to #55
Date(s) Self-Employed

Date(s) Self-Employed

Type of Business

Type of Business

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

$

Form SSA-8000-BK (01-2012)

Page 18

$

$

You

55. 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?

56.

YES
Explain in
Remarks;
then Go to
#56

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

NO
Go to #56

YES Go to (b)

NO Go to NOTE
Frequency:

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

Your Spouse
NO
YES
Go to #56
Explain in
Remarks;
then Go to
#56

$
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 #57; OTHERWISE, GO TO #58.
57. (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?
(d) Name of School

NO Go to #58

YES Explain absence
in Remarks and Go to (d)

Name of School Contact

Dates of Attendance
From
To

Course of Study

Hours Attending or
Planning to Attend

Phone Number

PART V - POTENTIAL ELIGIBILITY FOR FOOD STAMPS/MEDICAL ASSISTANCE/OTHER
BENEFITS - If a California resident, Skip to #59
NO
Go to (c)

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

YES
(b) Have you received a recertification notice within the
Go to (e)
past 30 days?

NO
Go to #59

YES
Go to (e)

NO
Go to #59

(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 #59

YES
Go to (e)

NO
Go to #59

You

58. (a) Are you currently receiving food stamps?

YES
Go to (b)

(e) If everyone in the household receives or is applying for SSI, Go to (f); otherwise Go to #59.
(f) May I take your food stamp application today?

YES
Go to #59

(g) Explanation:

Form SSA-8000-BK (01-2012)

Page 19

YES
NO
Explain in (g) Go to #59

NO
Explain in (g)

59. 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?

Your Spouse, if filing

YES
Go to (b)

NO
Go to #60

YES
Go to (b)

NO
Go to #60

(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 (c)

NO
Go to (c)

YES
Go to (c)

NO
Go to (c)

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

YES
Go to #60

NO
Go to #60

YES
Go to #60

60. (a) Have you ever worked under the U.S. Social
Security System?
(b) Have you, your spouse, or a former spouse (or
parent if you are filing as a child) ever:

YES Go to (b)

Yes

NO Go to (b)
Your
Spouse/Parent

You
No

NO
Go to #60

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 #14 or #60(a); otherwise Go to #61.
You:
Your Spouse, if filing/Your Parent, if filing as a child:

PART VI -- MISCELLANEOUS -- (Answer #61 ONLY IF YOU ARE APPLYING ON BEHALF OF SOMEONE
ELSE: OTHERWISE GO TO #62.

61. (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 (01-2012)

Page 20

PART VIII -- IMPORTANT INFORMATION AND SIGNATURES
62. IMPORTANT INFORMATION--PLEASE READ CAREFULLY
X 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.

X 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.
X 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.
63. 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.
Your Signature (First name, middle initial, last name) (Sign in ink.) Date (month, day, year)

SIGN
HERE

X

Telephone Number(s) where we can contact you
during the day:

(

)

-

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

SIGN
HERE

X

64. If you are blind or visually impaired, check the type of mail you want to receive from us.
Standard notice First Class
Standard notice Certified

Standard notice First-Class with a follow-up phone call
Standard & Braille notices by First-Class

Standard notice & data CD by First-Class

Standard & large print notices

Standard notice & audio CD

WITNESS

65.

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 (01-2012)

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.
Privacy Act Statement/ Paperwork Reduction 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 this information
to help us determine your entitlement to benefits. Furnishing us this information is voluntary. However, failing to provide us
with all or part of the requested information may prevent us from making an accurate and timely decision on your claim, which
may result in the loss of payments. We rarely use the information you supply for any purpose other than for determining
problems in Social Security programs. 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 Medicare 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 the 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.
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 use of routine uses for this information is available in System of Records Notices 60-0089, Claims Folder System and
60-0050, Completed Determination-Continuing Disability Determinations. These notices, additional information regarding this
form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or any local Social
Security office.

See Revised PRA Attached

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 (TTY 1-800-325-0778) or
• In person or
• By mail at the address shown above.

Form SSA-8000-BK (01-2012)

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
hospital or visit a relative.)
States
• 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.
--You begin living with someone as husband and
• Births and deaths of any people with whom you live.
wife.
• Your spouse or former spouse dies.
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
provide them to SSA when requested.)
• Have a change in the amount of money you receive.
• Become eligible for benefits other than SSI.
• Begin to receive child support payments or those
payments go up or down.
• Win money from gambling or a lottery.
HELP YOU GET FROM OTHERS -You must report to Social Security if:
• Someone stops helping you.
• Someone starts helping you.

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

THINGS OF VALUE THAT YOU OWN -You must report to Social Security if:
• You sell or give any thing of value away.
• The value of things that you own goes over $2000
when you add them all together ($3000 if you are
• You buy or are given anything of value.
married and live with your spouse).
YOU ARE BLIND OR DISABLED-You must report to Social Security if:
• You go to work.

• Your condition improves or your doctor says you
can return to work.

IF YOU ARE THE PARENT, STEP PARENT, OR REPRESENTATIVE PAYEE FOR A CHILD UNDER 18 - A report to
Social Security must be made if:
• There is a change in any income the child, his or her parent(s), step • There is a change in his or her parents' or step parents' marriage, a
change in the value of anything they own, or a change in their
residence.

parent, or brother(s) or sister(s) receive.

• There is a change in the student status of the child's brother(s) or
sister(s).

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:
• You will no longer be able or no longer wish to act as
• The person for whom you receive SSI checks has
that person's representative payee.
any 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.)
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 (01-2012)

Page 23

SSA will insert the following revised PRA Statement 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 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. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.