Form SSA-8202 Statement for Determining Continuing Eligibility Supplem

Form SSA-8202 (11-2017) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 8
OMB No. 0960-0145
For Official Use Only

Statement for Determining Continuing Eligibility for
Supplemental Security Income Payment
If the name and address below are not correct, please cross out the part that is
wrong and write in the correct information.

EI SSN
Spouse's Name
Spouse's SSN
Check the ones that apply

•

C

K

DO Code

NC

J

L

FS-APP

FS-REF

Interviewers Initials

Date Received

When answering these questions, refer to this date:
1.

Since the date above, have you moved to a new address?
Yes

No

Yes

No

Yes

No

Yes

No

If "Yes," please give your new address:
Address (Number, Street, City, State, and ZIP Code):

2.

Date you moved:

Since the date above, have you spent a full calendar month in a hospital, nursing home or any
place other than where you live?
(Also, include trips outside of the United States that lasted 30 days or more.)
If "Yes," please give the following information:

3.

Name(s) of place(s) where you stayed:

Address(es) (Number, Street, City, State,
ZIP Code)

Date(s) first stayed (month/day/year):

Date(s) left (month/day/year):

Since the date above, has anyone moved into or out of the place where you live? (Also, report
births and deaths of people living with you.)
If "Yes," please explain in the REMARKS section on page 5 of this form.

4.

Since the date above, has anyone given you (or your spouse living with you) any money, food,
or free place to live, or helped you pay your bills or your rent?
If "Yes," please give the following information:
Type of help:

How often you received help:

Amount of help:

Form SSA-8202 (11-2017) UF
5.

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Since the date above, have you, or your spouse living with you, earned money from working or
do you expect to earn money from working in the next 14 months? (DO NOT COUNT earnings
from self-employment.)

Yes

No

If you earned money from working, please give the following information:
a. Amount(s) of earning for past months:
Employer's
Name, Address, and
Phone Number

Name of Worker

Gross Wages
Amount

How Often
Paid

Dates of Employment

b. Estimates of Earnings for this month and future months:

Amount

Amount
6.

Month

Month

Month

Month

Month

Month

$

$

$

$

$

$

Month

Month

Month

Month

Month

Month

$

$

$

$

$

$

SINCE DATE ON PAGE 1, have you, or your spouse living with you, been self-employed or
expected to be self-employed in the current taxable year?
If "Yes," please give the following information:
Name of SelfEmployed Person

7.

Type of
Income

Last Year's
Gross Income

Net Income
(or Loss)

This Year's Estimated
Gross Income

Net Income
(or Loss)

SINCE DATE ON PAGE 1, have you, or your spouse living with you, been self-employed or
expected to be self-employed in the current taxable year?
If "Yes," please give the following information:
• Support (alimony, child support)
• Rental Income
• Interest/dividends (from bank accounts)
• Pensions/Annuities
• Any other cash payments or checks
• Temporary Assistance for Needy Families
(gifts, sick benefits, unemployment,
• Other
or worker's compensation)
DO NOT COUNT - Social Security, SSI, food Stamps, Federal Civil Service Pensions, Railroad
Retirement, Temporary Assistance for Needy Families or Veteran's Benefits.
If you (or your spouse living with you) RECEIVED ANY OF THE PAYMENTS LISTED ABOVE,
please give the following information:
Type of Payment Received

Payment Amount

How Often Received

Yes

No

Dates of SelfEmployment

Yes

No

Form SSA-8202 (11-2017) UF
8.

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A. Do you, or your spouse living with you, have any checking or savings accounts or any other
funds in the bank? Include any accounts where you have direct deposit of any money.

Yes

No

Yes

No

C. Do you give us permission to obtain any of your financial records from any financial institution?

Yes

No

Do you, or your spouse living with you, have any cash at home, stocks, bonds, notes, or
certificates of deposit?

Yes

No

Yes

No

If "Yes," please give the following information:
Name and Address of
Financial Institution

Type of Account

Account Balance

B. Does your name, or the name of your spouse living with you, appear on any other account
that you do not consider your own? Include any accounts where you have direct deposit of
any money?
If "Yes," please give the following information:
Name and Address of
Financial Institution

9.

Type of Account

Account Balance

If "Yes," please give the following information:
What You Have

The Value of What You Have

10. Do you, or your spouse living with you, own any land or buildings or does your name appear on
a deed or mortgage of any land or building where YOU DO NOT LIVE?
This includes inherited property, property outside the United States and/or any property your
name is on with other members of your family.

Form SSA-8202 (11-2017) UF

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11. SINCE THE DATE ON PAGE 1, have you (or your spouse living with you) sold, transferred title,
disposed of, or given away any money, or other property, including money or property in
foreign countries?

Yes

No

Yes

No

If "Yes," please give the following information:
What you sold, transferred title, disposed of,
or gave away

The Value of the Property

12. SINCE THE DATE ON PAGE 1, have you (or your spouse living with you) had any change in
health insurance coverage or other insurance that pays for medical bills?
DO NOT INCLUDE - Medicare or Medicaid
DO INCLUDE - Insurance, such as accident, automobile, or casualty if it covers medical bills for
any reason.

IF YOU LIVE IN CALIFORNIA, PLEASE DO NOT ANSWER QUESTION 13 BELOW.
13.

You

Your Spouse

A. Are you currently receiving food stamps?
If "Yes," go to "B." If "No," go to "C."

Yes

No

Yes

No

B. Have you received a recertification notice within the past 30 days?
If "Yes," go to "E." If "No," go to question 14.

Yes

No

Yes

No

C. Have you filed for food stamps in the last 60 days?
If "Yes," go to "D." If "No," go to "E."

Yes

No

Yes

No

D. Have you received a favorable decision?
If "Yes," go to question 14. If "No," go to "E."

Yes

No

Yes

No

E. Is everyone in the household applying for or receiving SSI?
If "Yes," go to "F." If "No," go to question 14.

Yes

No

Yes

No

F. May I take your food stamp application today?
If "Yes," go to question 14. If "No," explain in "G."

Yes

No

Yes

No

G. Explanation

Form SSA-8202 (11-2017) UF

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14. Please answer the following questions:
A. Are you age 62 or older?

Yes

No

B. If you are age 50 or older, are you a widow(er)?

Yes

No

C. If you are age 50 or older and divorced, is your divorced spouse deceased?

Yes

No

D. If you were disabled before age 22, do you have a parent who is age 62 or older,
or disabled, or deceased?

Yes

No

Yes

No

15. SINCE THE DATE ON PAGE 1, has a warrant been issued for your arrest in connection with a
crime, or an attempt to commit a crime, that is a felony (or in New Jersey, a high misdemeanor)
or for violation of a condition of probation or parole under Federal or State law?

If the address where you live is different from the address where you get your mail, please give the
address where you live:
Address (Number, Street, City, State, ZIP Code)

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 21 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.
Remarks:

Form SSA-8202 (11-2017) UF

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Important Information - Please Read Carefully
• 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.
• If you are disabled or blind, you must continue to accept any appropriate vocational rehabilitation services offered to you by the
State agency to which we refer you.

Authorizations/Signatures (Write in ink)
I/We give permission for the Social Security Administration to check the information I/we have given on this form and to ask my
employer(s) for information about my/our wages.
I/We declare under penalty of perjury that I/we 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/our knowledge.

Recipient Signature (Write in ink)
Your Signature (First name, middle initial, last name)
Sign
Here
Spouse's Signature (First name, middle initial, last name)
(Sign only if receiving SSI payments)

Date

Area Code and
Telephone Number
where you can be
reached

Date

Sign
Here

Witnesses (Write in ink)
If you sign by mark (X), two people who you know must witness the signing. The witnesses must sign below and give their full
names and addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number, Street, City, State, ZIP Code)

Address (Number, Street, City, State, ZIP Code)

Representative Payee (Write in ink)
Your title or relationship to the recipient

Area Code and Telephone Number where you can be reached

Address (Number, Street, City, State, ZIP Code)

Your full name (First name, middle initial, last name)
Please
Print Here

Please
Sign Here

Date

Form SSA-8202 (11-2017) UF

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KEEP THIS PAGE FOR YOUR RECORDS
Name

Social Security Number

Name

Social Security Number

Date

Telephone Number (include area code) to call if you have a Social Security Office you may visit in person or mail things to:
question or something to report.

Privacy Act Statement - Collection and Use of Private Information
Section 1611(c) of the Social Security Act, as amended, allows us to collect this information. We will use the information you
provide to attempt to determine if you continue to be eligible for supplemental security income payments.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an
accurate decision on your continuing eligibility for benefits and could result in the loss of benefits. We rarely use the information
you supply for any purpose other than what we state above, however, we may use the information for the administration of our
programs, including sharing information:

See Revised Privacy Act Attached

1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of
our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records
Notices, 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits System. Additional information
about this and other system of records notices and our programs is available from our Internet website at www.socialsecurity.gov
or at your local Social Security office. 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 incorrect payments or delinquent debts under these programs.

You Must Report Certain Changes
You must also report changes in income for your ineligible spouse or children who live with you, or your sponsor or sponsor's
spouse if you are an alien. You must also report if any of these people buy or sell anything of value. Remember, changes could
make your check bigger or smaller. A list of most of the changes you must report is on the next page.
The amount of your SSI check is based on the information you tell us. To continue getting the right payment amount, you must
report certain changes that happen to you. You must tell us about changes within 10 days after the month they happen. If you do
not report changes, we may have to take as much as $25, $50, or $100 out of future checks you receive.

How to Report Changes
There are several ways you can report changes.
• Call us, toll free, at 1-800-772-1213.
• Call your local Social Security Office at the number above.
• By mail or in person - see the address above.

Important Facts About Food Stamps
You can apply for food stamps at the Social Security office if
you and everyone in your household get or apply for SSI. The
Social Security office will help you fill out the food stamp
application. You do not have to go to the food stamp office to
apply.

Are You Working or Would You Like to Work
If you would like to work of if you are already working and would like to earn more, you should know about SSI rules known as
work incentives. These rules can help you keep your Medicaid and help you keep getting some SSI even though you are working.
If you want to know more about these rules, call us, toll free, at 1-800-772-1213 or write or visit any Social Security office.
If you call or visit, ask to speak to someone about work incentives.

Form SSA-8202 (11-2017) UF

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Changes to Report

✔

WHERE YOU LIVE - You must report to Social Security if:
• You move.
• You (or your spouse) leave your household for a
calendar month or longer. For example, you enter a
hospital or visit a relative.

✔

HOW YOU LIVE - You must report to Social Security if:
• Someone moves into or out of your household
• The amount of money you pay toward household
expenses changes.
• There are births and deaths of any people with whom
you live.

✔

• You sell or give anything of value away.
• You buy or are given anything of value.

• You violate a condition of your parole or probation under
Federal or State law.

YOU ARE BLIND OR DISABLED - You must report to Social Security if:
• Your condition improves or your doctor says you can
return to work.

✔

• Someone stops helping you.
• Someone starts helping you.

A WARRANT HAS BEEN ISSUED FOR YOUR ARREST - You must report to Social Security if:
• You flee prosecution or to avoid custody or confinement
after conviction for a crime, or an attempt to commit a
crime, which is a felony (or in New Jersey, a high
misdemeanor).

✔

• Your earnings go up or down.

THINGS OF VALE THAT YOU OWN - You must report to Social Security if:
• The value of your resources goes over $2,000 when you
add them all together ($3,000 if you are married and live
with your spouse).

✔

• You start to work or stop work.

HELP YOU GET FROM OTHERS - You must report to Social Security if:
• The amount of help ( money, food, or payment of
household expenses) you received goes up or down.

✔

• Your marital status changes:
- You get married, separated, divorced, or your
marriage is annulled.
- You separate from your spouse or start living together
again after a separation.
- You begin living with someone as a husband and wife.

INCOME - You must report to Social Security if:
• The amount of money (or checks or any other type of
payment) you receive from someone or someplace goes
up or down or your start to receive money (or checks or
any other type of payment).

✔

• You leave the United States for 30 days or more.
• You enter a jail, prison, or other penal institution.
• You are released from a hospital, nursing home, etc.
• You are no longer a legal resident of the United States.

• You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22 - You must report to Social Security if:
• You are under age 18 and live with your parent (s), ask
your parents to report if they have a change in income, a
change in their marriage, a change in the value of
anything they own, or either has a change in residence.

• You get married.
• There are changes in the income, school attendance
(if between the ages of 18 and 21), or marital status of
ineligible children who live in your household.

✔

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES You must report any changes to Social Security.

✔

YOU ARE A REPRESENTATIVE PAYEE - You must report to Social Security if:
• The person for whom you receive SSI checks has any of
the 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.)

• You will no longer be able or no longer wish to act as the
person's representative payee.