Form SSA-8203 Statement Determining Continuing Eligibility for Supplem

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Form SSA-8203-BK (10-2018)
RIGHTS AND RESPONSIBILITIES
Name

Social Security Number

Date

Name

Social Security Number

Date

Telephone Number (include
area code) to call if you have a
question or something to report

Social Security Office you may visit in person or send in your request:

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy
Act Statement

Section 1611 (c)(1) 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:
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 entitled Claims Folder System (60-0089) and Supplemental Security Income Record and Special Veterans Benefits
System (60-0103). Additional information about these 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.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 or the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (0MB)
control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Form SSA-8203-BK (10-2018)
CHANGES TO REPORT

0 WHERE YOU LIVE - You must report to Social Security if:
• You move.

• You leave the United States for 30 days or more.

• You (or your spouse leave your household for a calendar
month or longer. For example, you enter a hospital or visit
a relative.

• You are released from a hospital, nursing home, etc.
• You are no longer a legal resident of the United States.

D HOW YOU LIVE - You must report to Social Security:
• If someone moves into or out of your household.
• If the amount of money you pay toward household
expenses changes.
• If your former spouse dies.
• Births and deaths of any people with whom you live.

0 INCOME - You must report to Social Security if:

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• The amount of money (or checks or any other type of
payment) you receive from someone or someplace goes
up or down or you start to receive money (or checks or
any other type of payment).

• Changes in your marital status:
• 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 husband and wife.
• Your spouse dies.

• You start work or stop work.
• Your earnings go up or down.
• You become eligible for benefits other than SSI.

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

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

THINGS OF VALUE 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 sell or give any things of value away.
• You buy or are given anything of value.

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

• You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22 - A report to Social Security must be made 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.
• You start or stop school.

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.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 1611(c) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on continued
Supplemental Security Income benefits eligibility.
We will use the information to make a determination of eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
•
•

•

To contractors and another Federal agency, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its programs;
To State agencies, to identify Title XVI eligibles in the jurisdiction of those States which
have not elected Federal determinations of Medicaid eligibility, in order to assist those
States in establishing and maintaining Medicaid rolls and in administering the Medicaid
program; and
To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784; 60-0103, entitled SSI Record and Special Veterans Benefits, as
published in the FR on January 11, 2006, at 71 FR 1830; and 60-0320, entitled Electronic
Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional
information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.