Form SSA-8001-BK(revise Application For Supplemental Security Income

Form Approved
OMB No. 0960-0444

TEL

SOCIAL SECURITY ADMINISTRATION

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)

Do Not Write in This Space

(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
Parent(s)

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
Male

3. Birthdate
4. Social Security Number
(month, day, year)

Female
5 If filing as spouse or couple
(a) Spouse's Name(s)

6(a). Sex

7(a). Birthdate
8(a). Social Security Number(s)
(month, day, year)

Male
Female
If filing for child
(b) Parent 1's Name(s)

6(b). Sex

7(b). Birthdate
8(b). Social Security Number(s)
(month, day, year)

Male
Female
If filing for child
(c) Parent 2's Name(s)

6(c). Sex

7(c). Birthdate
8(c). Social Security Number(s)
(month, day, year)

Male
Female
8. (d) Are you married? Yes , complete (e) and (f) _____________
No, Go to (g)
(e) Date of Marriage (month, day,year)

(f) Are you and your spouse living together?

Yes

No If no, date you began living apart:

(g)Are you and another person living together in the same household and presenting to others or the community

as a married couple?

Yes, provide the date holding out began (month, day, year):________. Go to (h)*

No Go to #9

*(h) Other person's name (First, middle initial, last) ________________.
Other person's Social Security Number____________________. *Use SSA-4178 to develop the holding out relationship.
9. Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d)
(a). Your Other Name(s) (including Name at Birth)

Form SSA-8001-BK (07-2015)
Destroy Prior Editions

Social Security Number

Page 1

(b) Spouse's Other Name(s) (including Name at Birth)

Social Security Number

(c) Parent 1's Other Name(s) (including Name at Birth)

Social Security Number

(d) Parent 2's Other Name(s) (including Name at Birth)

Social Security Number

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).
You
(a) Are you unable to workor is your work limited
YES
NO
because of illnesses, injuries, or conditions?
Go to (b)
Go to #13
(month, day, year)
(b) Enter the date you became unable to work.
Go to (c)
(c)
Are you blind or do you have low vision even with
glasses or contacts?

YES

(d) If you were unable to work because of illnesses,
injuries, or conditions before age 22, do you have a
parent or stepparent who is age 62 or older,
unable to work because of illnesses, injuries, or
conditions
or deceased?
(e) When
did the child become disabled? (month, day year)

NO
Go to (d)

YES

Your Spouse, if filing
NO
YES
Go to #13
Go to (b)
(month, day, year)
Go to (c)
YES

NO
Go to (d)

NO

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

Go to #13
Go to (f)

(f) What are the child's disabling illnesses, injuries, or conditions?
Is the child blind or does he or she have low vision even with glasses or contacts?

YES NO

Go to (g)
(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?

YES

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).
(a) Are you a naturalized United States citizen?
(b) Are you an American Indian born outside the
United States?

Form SSA-8001-BK (07-2015)

You
YES
Go to #17

NO
Go to (b)
You

YES
Go to (c)

Page 2

NO
Go to (d)

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

13. (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)

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

Your Spouse, if filing
Go to #14
Go to #14

Refugee

Amerasian Immigrant
Lawful Permanent Resident

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

Asylee

Go to #16
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

Cuban/Haitian Entrant

Go to #14

Refugee

Date of entry (month, day, year):

Parolee for One Year

Go to #14

Go to #16
Go to #16

Deportation/Removal Withheld

Go to #16
Parolee for One Year
Cuban/Haitian Entrant

Go to #16
Go to #16

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.

Form SSA-8001-BK (07-2015)

Page 3

You
(month, day, year)

14. (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)

Your Spouse, if filing
(month, day, year)
YES
Go to (c)

(c) Give the following information about the person, institution or group:
Name
Address

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

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

NO
Go to (d)

Telephone Number

You
(month, day, year)

Your Spouse, if filing
(month, day, year)

From:

From:

To:

To:

YES
Go to (f)

NO
Go to #16

YES
Go to (f)

NO
Go to #16

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

Social Security Number

Name

Social Security Number
You

15 (a) Have you, your child, or your parent, been subjected

Your Spouse, if filing

to battery or extreme cruelty while in the United
States?

YES
Go to (b)

NO
Go to #17

YES
Go to (b)

NO
Go to #17

(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?

YES
Go to #16

NO
Go to #17

YES
Go to #16

NO
Go to #17

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

YES
NO
Explain in
Go to #17
Remarks, then
Go to #17

YES
NO
Explain in
Go to #17
Remarks, then
Go to #17

(month, day, year)

(month, day, year)

17. (a) When did you first make your home in the
United States?
(b) Have you lived outside of the United States
since then?

YES
Go to (c)

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

NO
Go to #18

(month, day, year)

YES
Go to (c)

Date

NO
Go to #18

(month, day, year)

Left:

Left:

(month, day, year)

(month, day, year)
Date

Date

Returned:

Returned:

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?
Form SSA-8001-BK
(07-2015)

YES
Go to (b)
Page 4

NO
Go to #19

YES
Go to (b)

NO
Go to #19

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

Form SSA-8001-BK (07-2015)

Date
Left:

(month, day, year)

(month, day, year)
Date
Left:

(month, day, year)

Date

Date

Returned:

Returned:

Page 5

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

Name of County (if any) in which Telephone
Number you live
State/Province/Region (Foreign)
Postal Code
Country
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
City and State (U.S.)

Standard notice & data CD by First-Class
Standard & Braille notices by First-Class

Standard notice Certified
Standard & large print notices

21. (a) Do you have any felony warrants for escape from
custody, flight to avoid prosecution or confinement,
or flight escape?

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

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

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

PART 2 - LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first
moment of the filing date month and today.)
22. Claimant's Residence Address
City and State (U.S)
State/Province/Region(Foreign)

ZIP Code
Postal Code

Name of County (if any) in which you live
Country

23. (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)
24. 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.
Alone

Form SSA-8001-BK (07-2015)

Spouse/Parents and/or Children

Page 6

Other People

PART 3 - RESOURCES (Show resources as of the first moment of the filing date month. Use
"Remarks" to explain any changes.)
25. 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

Co-owned
With Others
Yes
No

(a) Trusts
(b) Vehicles (auto, truck,
camper, boat, motorcycle).

Dollar Value
Spouse or
Parents Own

Dollar Value
You Own

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

How many?
(c) Property other than the
home you live in (land,
houses, buildings, property
in foreign countries)
(d) Savings, checking
accounts, stocks, bonds
(e) Cash at home, with you,
or anywhere else
(f) Items held for potential
value or investment (for
example, coin or card
collection, jewelry in safe
deposit box)
(g) Insurance policies

(h) Other items that can be
turned into cash
(i)

Achieving a
Better Life
Experience
Your Answer

26. Are there any assets set aside to meet burial expenses Spouse's Answer
for you or your spouse/parent(s)? (If "Yes" describe the
27 item in "Remarks".)
Parent 1’s Answer
Parent 2’s Answer
(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

You
YES

YES

NO

YES

NO

YES

NO

YES

NO

Your Spouse
NO

You

IF YOU
"YES"
TO (a) OR (b), GO TO (c). IFPage
"NO"7 TO BOTH, GO TO #28.
FormANSWERED
SSA-8001-BK
(07-2015)

YES
Your Spouse

NO

27 (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

$
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?

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

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

YES

You

Your Spouse, if filing
YES
NO

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.
29. 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

Amount

Frequency
Received

Date Last
Paid

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

Form SSA-8001-BK (07-2015)

Page 8

Source of
Income

NO
Go to #3

YES
Go to (b)

30 (a) Does your spouse/parent pay court ordered child support?
(b) Give the amount and frequency of payment:

$
PART 5 – POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
(SNAP)/MEDICAL ASSISTANCE
YES
Go to (b)

NO
Go to (c)

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

(b) Have you received a recertification notice within the
past 30 days?

YES
Go to (e)

NO
Go to #32

YES
Go to (e)

(c) Have you filed for SNAP benefits in the last
60 days?

YES
Go to (d)

(d) Have you received a favorable decision?

YES
Go to #32

NO
Go to (e)

YES
Go to #32

NO
Go to (e)

(e) May I take your SNAP application today?

YES
Go to #32

NO
Explain in (f)

YES
Go to #32

NO
Explain in (f)

31 (a) Are you currently receiving SNAP benefits (formerly
food stamps?

(f) Explanation:

You

NO
Go to (e)
You

NO
Go to #32

YES
NO
Go to (d)
Go to (e)
Your Spouse, if filing

32.
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 p a r e n t 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.
(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?
(b) Do you, your spouse, parent or stepparent have
any private, group, or governmental health

You
YES
Go to (b)

Go to #33

NO

YES
Go to (b)

Go to (c)

Go to (c)

YES
Go to #33

NO
Go to #33

insurance that pays the cost of your medical care?
(Do not include Medicare or Medicaid.)

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 #33

Go to #33

Form SSA-8001-BK (07-2015)

YES

Your Spouse, if filing

Page 9

NO

YES

NO
Go to #33

NO

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

33(b). Have you ever served as representative payee for a Social
Security beneficiary or SSI claimant?

YES,
No,
Go to #34

Form SSA-8001-BK (07-2015)

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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 (07-2015)

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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 a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
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 (07-2015)

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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.

Form SSA-8001-BK (07-2015)

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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.

See Revised Privacy Act Statement Attached

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 (07-2015)

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