Application for Supplemental Security Income--SSA-8000-BK (Paper Form)

Application for Supplemental Security Income (SSI)

Documents and Forms

Document Name Document Type
Form SSA-8000-BK Application for Supplemental Security Income--SSA-8000-BK (Paper Form) Form
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-8000-BK Application for Supplemental Security Income (SSI) SSA-8000-BK - Revised.pdf Form
SSA-8000-BK - Current.pdf SSA-8000-BK - Current IC Document

Information Collection (IC) Details

IC Title:	Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.207 20 CFR 416.305-.335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8000-BK	Application for Supplemental Security Income (SSI)	SSA-8000-BK - Revised.pdf		No		Fillable Printable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 705	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	705	-20,236	20,941
Annual IC Time Burden (Hours)	470	-13,840	14,310
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-8000-BK - Current	SSA-8000-BK - Current.pdf	11/30/2021

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