SSA-8001-BK (current)

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0444
Do Not Write in This Space

TEL

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
(Deferred or Abbreviated)

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.

DEFERRED

ABAP

SNAPSNAPSSA/APP
REFERRED
Filing Date (Month, Day, Year)

Receipt

Protective

Preferred Language:
Written:
Spoken:

TYPE OF CLAIM

Individual

Individual with
Ineligible Spouse

Couple

Child

Child with Parents

PART 1 - BASIC ELIGIBILITY- Answer the questions below beginning with the first moment of
the filing date month.
1.

First Name, Middle Initial, Last Name

2. Sex

3. Birthdate

4. Social Security Number

7. Birthdate

8. Social Security Number(s)

(month, day, year)

Male
Female
5.

Spouse's/Parent(s) Name(s)

6. Sex

(month, day, year)

Male
Female
Date of Marriage: (month, day, year)
Are you and your spouse living together?
9.

Yes

No

If no, date you began living apart:

Other Name(s) and Social Security Number(s) you, your spouse/parents used:
(a) Your Other Name(s) (including Maiden Name)
Your Other Social Security Number(s)

(b) Spouse's/Mother's Other Name(s) (including Maiden Name)

Spouse's/Mother's Other Social Security Number(s)

(c) Father's Other Name(s)

Father's Other Social Security Number(s)

Form SSA-8001-BK (08-2012)
Destroy Prior Editions

Page 1

10. Your Place of Birth (City and State or Foreign Country)

11. Spouse's Place of Birth (City and State or Foreign Country)

12. 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?
(b) Enter the date you became unable to work.
(c) What are your illnesses, injuries, or conditions?

You

Your Spouse, if filing

YES
NO
Go to (b)
Go to #13
(month, day, year)

NO
YES
Go to #13
Go to (b)
(month, day, year)

(Brief Description)

Go to (c)

(Brief Description)

Go to (d)
(d) If you were unable to work because of illnesses,
injuries, or conditions before 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

Go to (c)

Go to (d)
NO

Provide name(s) and
Social Security
Number(s) in Remarks.
Go to #13

Go to #13

(e) When did the child become disabled? (month, day year)

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

Go to (g)
YES

(g) Does the child have a parent or stepparent who is 62
or older, unable to work because of illnesses,
injuries, or conditions, or deceased?

NO

Provide name(s) and
Social Security
Number(s) in Remarks.
Go to #13

Go to #13
13. If you (and your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a).
You

(a) Are you a naturalized United States citizen?

YES
Go to #17

Your Spouse, if filing

NO
Go to (b)
You

(b) Are you an American Indian born outside the
United States?

YES
Go to (c)

YES
Go to #17

NO
Go to (b)

Your Spouse, if filing

NO
Go to (d)

YES
Go to (c)

NO
Go to (d)

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

American Indian born in Canada

Your Spouse, if filing

Go to #17

American Indian born in Canada

Go to #17

Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17

Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17

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

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

Form SSA-8001-BK (08-2012)

Page 2

13. (d) Check the block below that shows your current immigration status.
You
Amerasian Immigrant
Lawful Permanent Resident

Your Spouse, if filing
Amerasian Immigrant

Go to #14

Go to #14

Lawful Permanent Resident

Go to #14

Refugee

Refugee

Date of entry (month, day, year):

Date of entry (month, day, year):
Go to #16

Go to #16

Asylee

Asylee

Date status granted (month, day, year):

Date status granted (month, day, year):
Go to #16

Go to #16

Conditional Entrant

Conditional Entrant

Date status granted (month, day, year):

Date status granted (month, day, year):
Go to #16

Parolee for One Year
Cuban/Haitian Entrant

Go to #14

Go to #16
Parolee for One Year

Go to #16

Go to #16

Cuban/Haitian Entrant

Go to #16

Go to #16

Deportation/Removal Withheld

Deportation/Removal Withheld
Date (month, day, year):

Date (month, day, year):
Go to #16

Other
Explain in Remarks, then Go to (e)

Go to #16
Other
Explain in Remarks, then Go to (e)

(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United States citizen, or
a lawfully admitted permanent resident, Go to #15; otherwise Go to #17.
14. (a) Date of admission:

You

Your Spouse, if filing

(month, day, year)

(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:
Name

Address

Telephone Number

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

You

Your Spouse, if filing

(month, day, year)

(month, day, year)

From:

From:

To:

To:

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

YES
Go to (f)

NO
Go to #16

YES
Go to (f)

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

Social Security Number

Name

Social Security Number

Form SSA-8001-BK (08-2012)

Page 3

NO
Go to #16

15.

(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?

16.
Are you, your spouse, or parent an active duty member
or a veteran of the armed forces of the United States?
17. (a) When did you first make your home in the United
States?

You
YES
Go to (b)

NO
Go to #17

Your Spouse, if filing
YES
NO
Go to (b)
Go to #17

YES
Go to #16

NO
Go to #17

YES
Go to #16

YES Explain in
Remarks, then
Go to #17
NO Go to #17
(month, day, year)
YES
Go to (c)

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

(c) Give the date(s) of residence outside the United
States.

18. (a) Have you been outside the United States (the 50
States, District of Columbia and Northern Mariana
Islands) 30 days prior to the filing date?

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

NO
Go to #17

YES Explain in
Remarks, then
Go to #17
NO Go to #17
(month, day, year)

NO
Go to #18

YES
Go to (c)

NO
Go to #18

(month, day, year)
Date
Left:

(month, day, year)
Date
Left:

(month, day, year)
Date
Returned:

(month, day, year)
Date
Returned:

YES
Go to (b)

YES
Go to (b)

NO
Go to #19

NO
Go to #19

(month, day, year)
Date
Left:

(month, day, year)
Date
Left:

(month, day, year)
Date
Returned:

(month, day, year)
Date
Returned:

19. Claimant's Mailing Address (Number & Street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Name of County (if any) in
which you live

Telephone Number

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

Standard notice First-Class with a follow-up phone call

Standard notice & data CD by First-Class

Standard notice Certified

Standard & Braille notices by First-Class

21.

Standard & large print notices

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

Standard notice & audio CD

You
YES
NO
Go to (b)
Go to #22
Name of State/Country

Your Spouse, if filing
YES
NO
Go to (b)
Go to #22
Name of State/Country

(b) In which State or country was the warrant issued?
Go to (c)
(c) Was the warrant satisfied?
(d) Date warrant satisfied:

Form SSA-8001-BK (08-2012)

YES
NO
Go to (d)
Go to #22
(month, day, year)

Page 4

Go to (c)
YES
NO
Go to (d)
Go to #22
(month, day, year)

You

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

YES
NO
Go to (b)
Go to #23
Name of State/Country

Your Spouse, if filing
YES
NO
Go to (b)
Go to #23
Name of State/Country

(b) In which State or country was the warrant issued?
Go to (c)
YES
NO
Go to (d)
Go to #23
(month, day, year)

(c) Was the warrant satisfied?
(d) Date warrant satisfied:

Go to (c)
YES
NO
Go to (d)
Go to #23
(month, day, year)

PART 2 - LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first
moment of the filing date month and today.)
23. Claimant's Residence Address

City and State

ZIP Code

Name of County (if any) in which you live

24. (a) Mark the box that describes where you live.
House, apartment, mobile home, houseboat

Noninstitution (rest home, retirement home, foster
home, or group home)

Room in commercial establishment

Institution (hospital, rehabilitation center, prison, or
school)

Room in private home

Transient or homeless

(b) Date you began living there: (month, day, year)
25. Mark the box that describes with whom you live. If you live in a foster home, group home, or an institution, or if you are
a transient or homeless, do not answer but explain in remarks.
Spouse/Parents and/or Children

Alone

Other People

PART 3 - RESOURCES (Show resources as of the first moment of the filing date month. Use
"Remarks" to explain any changes.)
26.

If you own, or your name or your spouse's/parent's name(s) appear on any of the following items (either alone or with
other people's name(s)), enter the total cash value of item(s) on each line.

YES NO

Description of Items
Marked YES

a. Vehicles (cars, trucks,
boats, motorcycles).
How many?
b. Insurance policies

c. Cash at home, with you,
or anywhere else
Form SSA-8001-BK (08-2012)

Page 5

Co-owned
With Others
No
Yes

Dollar Value
You Own

Dollar Value
Spouse or
Parents Own

$

$

$

$

$

$

26.
YES NO

Description of Items
Marked YES

Co-owned
With Others
No
Yes

d. Savings, checking
accounts, stocks, bonds

e. Trust(s)
f. Property other than the
home you live in
g. Life estates or property
you inherited
h. Other items that can be
turned into cash
27.

Dollar Value
You Own

$

$

$

$

$

$

$

$

$

$

Your Answer
Are there any assets set aside to meet burial expenses Spouse's Answer
for you or your spouse/parent(s)? (If "Yes" describe the
Mother's Answer
item in "Remarks".)
Father's Answer

28. (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

YES

NO

YES

NO

YES

NO

YES

NO

Your Spouse
NO

YES

You
YES

Dollar Value
Spouse or
Parents Own

NO

Your Spouse
NO

YES

NO

IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #29.
(c)

OWNER'S/CO-OWNER'S NAME

DESCRIPTION OF PROPERTY

DATE OF DISPOSAL

NAME AND ADDRESS OF
PURCHASER OR RECIPIENT

RELATIONSHIP TO OWNER

VALUE OF PROPERTY AND/
OR AMOUNT OF CASH GIFT

Item#1
Item #2
Item #3

Item #1

$

Item #2

$

Item #3

$

Form SSA-8001-BK (08-2012)

Page 6

28.

SALE PRICE OR OTHER
CONSIDERATION

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

Item #1

YES

NO

Item #2

YES

NO

Item #3

YES

NO

SOLD ON OPEN MARKET?

29.

TRADED FOR GOODS/
SERVICES?

GIVEN AWAY?

Item #1

YES

NO

YES

NO

YES

NO

Item #2

YES

NO

YES

NO

YES

NO

Item #3

YES

NO

YES

NO

YES

NO

Do you give us permission to obtain any financial
records from any financial institution?

YES

You

Your Spouse, if filing
NO
YES

NO

PART 4 - INCOME (List all income received since the first moment of the filing date month or
expected in the next 3 months.) Include you, your spouse/parents.
30.

List cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect to receive.
Include income from wages, sick pay, self-employment, interest, social security, assistance based on need, VA, gifts,
pensions, and any other type of income. Give date last paid if income will stop in the next 3 months.
Person Receiving
Income

Type of Income

Frequency
Received

Amount

Date Last
Paid

Source of
Income

$
$
$
Also, note here if anyone pays any bills for you directly or gives you money to pay them.
31.

YES
Go to (b)

(a) Does your spouse/parent pay court ordered child support?

NO
Go to #32

(b) Give the amount and frequency of payment:

$
PART 5 - SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
32.

(a) Are you currently receiving SNAP benefits (formerly
food stamps?
(b) Have you received a recertification notice within the
past 30 days?
(c) Have you filed for SNAP benefits in the last
60 days?

Form SSA-8001-BK (08-2012)

You
YES
Go to (b)

NO
Go to (c)

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

YES
Go to (e)

NO
Go to #33

YES
Go to (e)

NO
Go to #33

NO
Go to (e)

YES
Go to (d)

NO
Go to (e)

YES
Go to (d)
Page 7

You

32.

Your Spouse, if filing

(d) Have you received a favorable decision?

YES
Go to #33

NO
Go to (e)

YES
Go to #33

NO
Go to (e)

(e) May I take your SNAP application today?

YES
Go to #33

NO
Explain in (f)

YES
Go to #33

NO
Explain in (f)

(f) Explanation:

PART 6 - MISCELLANEOUS
ANSWER #33 ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISE
GO TO #34.
33. Name of Person Requesting Benefits
Relationship to Claimant
Your Social Security Number

PART 7 - 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-8001-BK (08-2012)

Page 8

PART 8 - IMPORTANT INFORMATION - PLEASE READ CAREFULLY
34.

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 cancelling 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.

PART 9 - SIGNATURES
35.

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.

36. Your Signature (First name, middle initial, last name) (Write in ink.)

Date (Month, day, year)

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

WITNESSES
38.

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-8001-BK (08-2012)

Page 9

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 write to:

Your application for Supplemental Security Income will be processed as quickly as possible. You should hear from us within _____days.
If you do not hear from us within that time, please get in touch with us in person, by mail, or call us at the telephone number shown at the
top of this page.
We may need more information before we can decide whether or not you are eligible for SSI payments. If we need more information, we
will contact you. In the meantime, if you move or change your mailing address, you (or someone for you) should report the change to the
office shown at the top of this page.
You (or someone for you) must let us know if your immigration status changes.
Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. You could lose some SSI
payments if you do not let us know right away.
Always give your Social Security Number when writing or telephoning about your claim. If you have any questions about your claim, we
will be glad to help you.

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 give us when we match records by computer. Matching programs compare our records with those
of other Federal, State or local government agencies. 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.
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.
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 19-20 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 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-8001-BK (08-2012)

Page 10