Information Collection

Application for Supplemental Security Income

IC 188727 under ICR 201907-0960-002 · OMB 0960-0444.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0444 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8001-BK(revise Application for Supplemental Security Income	Form
SSA-8001-BK - Revised Privacy Act Statement.pdf	Other-Revised Privacy Act Statement
SSA-8001-BK(revise Application For Supplemental Security Income SSA-8001-BK - Revised Version.pdf	Form
SSA-8001-BK - Current Version.pdf Current SSA-8001-BK	IC Document

IC Title:

Application for Supplemental Security Income

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.305 - 416.335

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-8001-BK(revised)	Application For Supplemental Security Income	SSA-8001-BK - Revised Version.pdf		No		Paper Only
Other-Revised Privacy Act Statement			SSA-8001-BK - Revised Privacy Act Statement.pdf		No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,588

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	Previously Approved
Annual Number of Responses for this IC	2,588	2,588
Annual IC Time Burden (Hours)	863	863
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-8001-BK	SSA-8001-BK - Current Version.pdf	02/20/2019

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