SSA-8010-BK - Current

Form SSA-8010-BK (10-2019) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 11
OMB No. 0960-0124

STATEMENT OF INCOME AND RESOURCES

D.O. Use
Name of Applicant/Recipient

I am/We are providing this statement on behalf of
Social Security Number
to determine his/her eligibility 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
Filing Date
Social Security Administration, and where applicable, for medical assistance MM
DD
YYYY
under title XIX of the Social Security Act.
Date of Last Determination
MM
DD
YYYY

OR

PERSONS REPORTING INCOME AND/OR RESOURCES
First Name, Middle Initial, Last Name

Spouse's Name (First, middle initial, last)

Social Security Number

Social Security Number

Check Which:

Sponsor

Ineligible Child

Parent

Essential Person

Check Which: (Spouse of)

Sponsor
Parent

1. PUBLIC INCOME MAINTENANCE PAYMENTS
You
(Governmental Assistance Based on Need)
(a) Have you received any of the public income maintenance payments
Yes
No
listed in (b) below since the first moment of the filing date month or
the last determination, or do you expect to receive them in any of the Go to (b) Go to #3
next 14 months?

Your Spouse
Yes
Go to (b)

No
Go to #3

(b) Give the following information about the payments:
PERIOD EXPECTED
REC'D HOW
IDENTIFICATION
TYPE
COVERED RECEIPT
AMOUNT
SOURCE
BY OFTEN
NUMBER
BY INCOME
DATE*
You
$
Supplemental
Social Security
Monthly
Security Income
Your
Administration
$
Spouse
State or Local GovYou
$
>
ernment Assistance
Your
$
>
Based on Need
Spouse
Refugee Assistance You
$
>
Payments Based on
Your
$
>
Need
Spouse
You
$
>
Aid to Families with
Dependent Children Your
$
>
Spouse
General Assistance
You
$
>
Bureau of
from the Bureau of
Your
Indian
Affairs
$
>
Indian Affairs
Spouse
You
$
Disaster Relief
Your
$
Spouse
Dept.of
You
$
Veterans Benefits
Veterans
Based on Need
Your
$
Affairs
Spouse
* If you are not receiving this income this month but expect it, enter the date you think you will receive it.
>If your share of the grant is unknown, enter the amount of the monthly family grant.
2. OTHER INCOME YOU RECEIVED WHILE RECEIVING PUBLIC
INCOME MAINTENANCE PAYMENTS
(a) Have you received any other income in addition to any public income
maintenance payments shown in #1?

You
Yes
Go to (b)

Your Spouse
No

Go to #6

Yes
Go to (b)

No
Go to #6

Form SSA-8010-BK (10-2019) UF
2. (b) If you are:
• The sponsor of an alien
(cont)
• The spouse of a sponsor
• An essential person

Page 2 of 11
Then:
Answer questions 3, 4, and 5 about your other income.

• A parent
• The spouse of a parent

If you have received these public income maintenance payments
continuously since the date shown on page 1 AND you expect to continue
receiving these payments this month and for the next 14 months, go to #6;
OTHERWISE, go to #3.

• An ineligible child

If you have received and expect to continue receiving these public income
maintenance payments as described above, go to #17; OTHERWISE, go to
#3.

3.
(a) Have you received wages since the first moment of the filing date
month or since the last determination?

You
Yes

No

Go to (b)

Go to (d)

Your Spouse
Yes
No
Go to (b)

Go to (d)

(b) Name and Address of Employer (include telephone number and area code, if known)
You

Your Spouse

(c) Total wages received (before any deductions) for each month:
Month(s)

You

Amounts
Your Month(s)
Spouse Amounts
You
Yes

(d) Do you expect to receive any wages in the next 14 months?

No

Go to (e)

Go to #4

Your Spouse
Yes
No
Go to (e)

Go to #4

(e) Name and address of employer if different from 3(b) (include telephone number and area code, if known)
You

Your Spouse

(f) Give the following information:
RATE OF PAY
You

$

per

Your
Spouse $

per

AMOUNT WORKED PER
PAY PERIOD

HOW OFTEN
PAID

PAY DAY OR
DATE PAID

You
(g) Do you expect any change in wage information provided in 3(f)?

Yes
Go to (h)

(h) Explain change:
You

Your Spouse

No
Go to #4

DATE LAST PAID
(MM/DD/YYYY)

Your Spouse
Yes
No
Go to (h)

Go to #4

Form SSA-8010-BK (10-2019) UF
4. (a) Have you been self-employed at any time since the beginning of the
taxable year in which the filing date month or the last determination
occurs or do you expect to be self-employed in the current taxable
year?
(b) Give the following information:
TYPE OF BUSINESS

You
Your
Spouse

Page 3 of 11
You
Yes
Go to (b)

Your Spouse
No

Go to #5

Yes
Go to (b)

LAST YEAR'S:
NET
GROSS
INCOME INCOME
LOSS
$
$
$

THIS YEAR'S:
NET
GROSS
INCOME INCOME
LOSS
$
$
$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

5. (a) Since the first moment of the filing date month or the last
determination, have you received or do you expect to receive
income in the next 14 months from any of the following sources?
FEDERAL BENEFITS:
Social Security
Railroad Retirement
Veterans Affairs Benefits Not Based on Need
Office of Personnel Management (Civil Service)
Military Pension, Special Pay, or Allowance
Black Lung
Earned Income Tax Credits
STATE/LOCAL BENEFITS:
Unemployment Compensation
Worker's Compensation
State Disability
State or Local Pension
PRIVATE BENEFITS:
Employer or Union Pension
Insurance or Annuity Payments
Private Needs-Based Assistance
MISCELLANEOUS:
Interest (bank accounts, stocks, CD's, etc.)
Rental/Lease Income
Dividends/Royalties
Alimony/Cash Support
Child Support
OTHER INCOME NOT PREVIOUSLY MENTIONED:

You
Yes

No
Go to #5

DATES OF
SELFEMPLOYMENT

Your Spouse
No

Yes

No

Form SSA-8010-BK (10-2019) UF
5. (b) Give the following information for any "Yes" answer in 5(a); otherwise go to #6
(cont)
Source (Name/Address of
Person
Type of
Dates Expected
Amount
Frequency
Person, Bank, Company, or
Receiving Income
or Received
Organization)
You

Page 4 of 11
Identifying
Number

From:

$

To:
You

From:

$

To:
You

From:

$

To:
Your
Spouse

$

Your
Spouse

$

Your
Spouse

$

From:
To:
From:
To:
From:
To:

6. RESOURCES

You
Yes

(a) Do you own or are you buying any real estate other than the
home in which you live?

Your Spouse
Yes
No

No

Go to (b)

Go to #7

Go to (b)

Go to #7

(b) Give the following information:
DESCRIPTION OF PROPERTY (Include type and size of structure, HOW IS IT USED? (If not used now, when was it
acreage or lot size, location.)
last used and what is next planned use?)
Item 1

Item 2

ESTIMATED
CURRENT
MARKET VALUE

OWNER'S NAME

AMOUNT OF
TAX ASSESSED
MORTGAGE
VALUE
PAYMENT

AMOUNT
OWED ON
ITEM

Item 1

$

$

$

$

Item 2

$

$

$

$

7.
(a) Do you own or does your name appear on the title of any
vehicles; e.g., cars, trucks, boats, motorcycles, etc. ?
(b)
OWNER'S NAME

DESCRIPTION
(YEAR, MAKE &
MODEL)

You
Yes
Go to (b)
USED FOR

Your Spouse
Yes
No

No
Go to #8

Go to (b)

Go to #8

EQUIPPED FOR CURRENT
HANDICAPPED? MARKET
VALUE
YES
NO

AMOUNT
OWED

$

$

$

$

$

$

Form SSA-8010-BK (10-2019) UF
8.

Page 5 of 11
You
Yes

(a) Do you own or are you buying any life insurance policies?

No

Go to (b)

Go to #9

Your Spouse
Yes
No
Go to (b)

Go to #9

(b) Give the following information on each policy:
NAME OF INSURED

OWNER'S NAME

NAME AND ADDRESS OF INSURANCE COMPANY

Policy (#1)

Policy (#2)

Policy (#3)
POLICY NUMBER

CASH SURRENDER VALUE

FACE VALUE

Policy (#1)

$

$

Policy (#2)

$

$

Policy (#3)

$

$

9.

DATE
PURCHASED

You

LOANS AGAINST
YES

NO

Your Spouse

(a) Do you (either alone or jointly with any other person) own any:
Yes

No

Yes

No

Life estates or ownership interest in an unprobated estate?
Items acquired or held for their value as an investment?
Other equipment (business or non-business) or property of any
kind?
(b) Give the following information for any "Yes" answer in 9(a); otherwise go to #10:
WHERE APPROPRIATE, GIVE
AMOUNT
OWNER'S NAME
NAME OF ITEM
VALUE
OWED ON NAME AND ADDRESS OF BANK
OR OTHER ORGANIZATION
ITEM

10.

$

$

$

$

(a) Do you own or does your name appear (either alone or with any
other person's name) on any of the following items?
Cash at home, with you, or anywhere else
Checking Accounts
Savings Accounts
Credit Union Accounts
Christmas Club Accounts
Certificates of Deposit
Notes
Stocks or Mutual Funds
Bonds
Other items that can be turned into cash

You
Yes

Your Spouse
No

Yes

No

Form SSA-8010-BK (10-2019) UF
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10. (b) Give the following information for any "Yes" answer in 10(a); otherwise go to #11.
NAME AND ADDRESS OF BANK AMOUNT
(cont)
OWNER'S NAME
NAME OF ITEM
VALUE
OR OTHER ORGANIZATION IF OWED ON
APPROPRIATE
ITEM
$

$

$

$

$

$

$

$

11. Do you give us permission to obtain any financial records from any
financial institution?
12. (a) Do you have any assets set aside for burial expenses such as
burial contracts, trusts, agreements, or anything else you intend
for your burial expenses? Include any assets mentioned in items
#6 through #10 above.
(b) DESCRIPTION (Where appropriate, give name
and address of organization and account policy
number)

VALUE

Item 1

$

Item 2

$

FOR WHOSE BURIAL

IS ITEM
IRREVOCABLE?

You
Yes

No
You

Yes

Your Spouse
Yes
No
Your Spouse

No

WHEN SET
ASIDE
(MM/DD/YYYY)

Yes

No

OWNER'S NAME

WILL INTEREST EARNED OR APPRECIATION
IN VALUE REMAIN IN THE BURIAL FUND?

Item 1

Yes

No

Yes Go to #13

No Explain in (c)

Item 2

Yes

No

Yes Go to #13

No Explain in (c)

(c) Explanation:

Item 1

Item 2

Form SSA-8010-BK (10-2019) UF
13. (a) Do you own any cemetery lots, crypts, caskets, vaults, urns,

Page 7 of 11
You
Yes

mausoleums or other repositories for burial or any headstones
or markers?

No

Go to (b)

(b)
OWNER'S NAME

DESCRIPTION

Your Spouse
Yes
No

Go to #14

Go to (b)

CURRENT
MARKET
VALUE
(if applicable)

RELATIONSHIP TO
YOU OR YOUR
SPOUSE

FOR WHOSE
BURIAL

Go to #14

$
$
14.

You

(a) Are you the sponsor of an alien admitted for permanent
residence in the United States?

Yes

Your Spouse
Yes
No

No

Go to (b)

Go to #18

Go to (b)

Go to #18

(b) If you are filing this report on behalf of the alien claimant/recipient, go to #15. If you are filing this report on behalf of
your child (or your spouse's child) who is applying for/eligible for SSI, go to #17.
15.

You
Yes

(a) Do you have any dependents?

Go to (b)

Your Spouse
Yes
No

No
Go to #16

Go to (b)

Go to #16

(b) Give the following information about your dependent(s):
RELATIONSHIP TO
YOU OR SPOUSE

NAME

FILING FOR/RECEIVING SSI

16. A sponsor may be liable for any overpayments made to an alien that
You
Yes
No
result from the sponsor's failure to provide correct information
regarding deemable income and resources. Do you agree to notify
Go to #18 Explain in
the Social Security Administration immediately about any changes in
Remarks
your income and resources and do you also agree to report any
and go to
change in your address?
#18

Your Spouse
Yes
No
Go to#18

Explain in
Remarks
and go to
#18

17. Give the following information about the alien(s) you sponsor:
NAME OF ALIEN

SOCIAL SECURITY
NUMBER

SPONSOR
You

Spouse

DATE OF
ADMISSION

FILING FOR/
RECEIVING SSI

Form SSA-8010-BK (10-2019) UF
Page 8 of 11
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-8010-BK (10-2019) UF

Page 9 of 11

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.
• 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 the applicant recipient is 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 the SSI
applicant or recipient is eligible or continues 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 notify us in writing that you are canceling
your permission, (2) we no longer consider your income and resources to be available to the SSI applicant or recipient,
(3) the SSI applicant is denied benefits in a final decision, or (4) the SSI recipient's eligibility for benefits terminates. If you
do not give or cancel your permission the SSI applicant or recipient may not be eligible for SSI and we may deny their
claim or stop their payments.

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

DATE (MM/DD/YYYY)
Telephone number(s) at which you
may be contacted during the day

Spouse's Signature (First name, middle initial, last name) (Write in ink)
NOTE: If you are the representative payee and are filing this statement on behalf of another person (other than your
spouse), please print below your full name, followed by your title or relationship to the person whose income and
resources you are reporting (for example, " John J. Jones, Son").
Title or Relationship

Name (First, middle initial, last)
Your Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)
City and State

ZIP Code

Enter name of county (if any) in which you live

Your Residence Address (if different from your mailing address)
City and State

ZIP Code

Enter name of county (if any) in which you live

WITNESSES
Your statement does not normally 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 addresses.
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-8010-BK (10-2019) UF

Page 10 of 11
Privacy Act Statement
Collection and Use of Personal Information

Sections 1612(a), 1613(a), 1614(f), 1621, and 1631(e) of the Social Security Act, as amended allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent
and accurate and timely decision on the claim filed.
We will use the information to make an initial or continuing Supplemental Security Income (SSI) eligibility determination.
We may also share your information for the following purposes, called routine uses:
1. To State agencies to enable them to assist in the effective and efficient administration of the SSI program; and
2. To representative payees, when the information pertains to individuals for whom they serve as representative payees,
for the purpose of assisting the Social Security Administration in administering its representative payment
responsibilities under the Social Security Act and assisting the representative payees in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they serve as payees.
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 Notice (SORN) 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits. Additional information and a full listing of all our
SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
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 12 minutes to read the instructions, gather the facts, and answer
the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is 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.
NAME OF SSI CLAIMANT/RECIPIENT

SOCIAL SECURITY NUMBER

DATE

Reporting Responsibilities
The amount of a Supplemental Security Income check is based on the information told to us. You must tell Social
Security every time there is a change - while we process this application AND if the person named above starts
receiving Supplemental Security Income. So that the individual continues getting the right payment amount, you
must report certain changes that happen to you.
Remember a change may make the SSI monthly payment bigger or smaller. Report changes in your income and
the income of your husband/wife or a child who lives with you. You must also report changes in things of value
that you and your spouse own.
You must tell us about any change within 10 days after the month it happens. If you do not report changes, we
may have to take as much as $25, $50, or $100 out of future checks the individual is due.
• HOW TO
REPORT

You can make your reports by telephone at the telephone number shown below or you may report in
person or by mail at the address shown below. See reverse side of this page for "Changes to Report."

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

Social Security Office you may come in person or mail your request to:

KEEP THIS PAGE FOR YOUR RECORDS

Form SSA-8010-BK (10-2019) UF

Page 11 of 11
CHANGES TO REPORT

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

• You are no longer a legal resident of the
United States.

• 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.
• Births and deaths of any people with whom you live.

• 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 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 you start to receive money (or checks or any other
type of payment).

• You start work or stop work.
• Your earnings go up or down.

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 any thing of value.

YOU ARE UNMARRIED AND UNDER AGE 21 - A report to Social Security must be made if:
• You stop or start school.
• You get married.

• Your income changes.

YOU ARE SELECTED AS A REPRESENTATIVE PAYEE - You must report to Social Security if:
• The person for whom you are filing this statement 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 that person's representative payee.
KEEP THIS PAGE FOR YOUR RECORDS