Information Collection

Application for Supplemental Security Income--Paper Version

IC 44924 under ICR 201406-0960-005 · OMB 0960-0229.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0229 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8000-BK Application for Supplemental Security Income--Paper Version	Form
SSA-8000-BK Application for Supplemental Security Income (Revised) SSA-8000-BK - Revised Version.pdf	Form
SSA-8000-BK - Current Version.pdf Current SSA-8000-BK	IC Document

IC Title:

Application for Supplemental Security Income--Paper Version

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 416.207 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-8000-BK	Application for Supplemental Security Income (Revised)	SSA-8000-BK - Revised Version.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: 39,295

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	39,295	13,670	25,625
Annual IC Time Burden (Hours)	26,852	9,342	17,510
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-8000-BK	SSA-8000-BK - Current Version.pdf	08/14/2014

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