Information Collection

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

IC 44924 under ICR 202109-0960-001 · OMB 0960-0229.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8000-BK Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Form
Form SSA-8000-BK Application for Supplemental Security Income (SSI) Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Form
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
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 Application for Supplemental Security Income (SSI) SSA-8000-BK - Revised.pdf	Form
SSA-8000-BK - Current.pdf SSA-8000-BK - Current	IC Document
SSA-8000-BK - Current.pdf SSA-8000-BK - Current	IC Document

IC Title:

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:

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-8000-BK				No		Fillable Printable
Other-Revised PA & PRA Statements					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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8000-BK - Current		11/30/2021

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

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