Form SSA-8202-BK Statement for Determining Continuing Eligibility Supplem

FORM APPROVED
OMB No. 0960-0145

TEL

SOCIAL SECURITY ADMINISTRATION

STATEMENT FOR DETERMINING
CONTINUING ELIGIBILITY FOR SUPPLEMENTAL
SECURITY INCOME PAYMENT

For Official Use Only
El SSN
Spouse's Name
Spouse's SSN

If the name and address below are not correct, please cross out
the part that is wrong and write in the correct information.

Check the Ones That Apply
C

•

J

K

FS-APP

DO CODE
NC
L

FS-REF

Interviewer's Initials

Date Received

WHEN ANSWERING THESE QUESTIONS, REFER TO THIS DATE
1.

SINCE THE DATE ABOVE, have you moved to a new address?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

If ''YES,'' please give your new address:
DATE YOU MOVED

ADDRESS (Number, Street, City, State, ZIP Code)
2.

SINCE THE DATE ABOVE, have you spent a full calendar month in a hospital, nursing home or
any place other than where you live? (Also, include trips outside of the United States that lasted 30
days or more.)
If "YES," please give the following information:

3.

NAME(S) OF PLACE(S) WHERE YOU STAYED:

ADDRESS(ES) (Number, Street, City State, ZIP Code)

DATE(S) FIRST STAYED (month/day/year)

DATE(S) LEFT (month/day/year)

SINCE THE DATE ABOVE, has anyone moved into or out of the place where you live
(also, report births and deaths of people living with you)?
If "YES," please explain in the REMARKS section on pages 4 and 5 of this form.

4.

SINCE THE DATE ABOVE, has anyone given you (or your spouse living with you) any
money, food, or a free place to live, or helped you pay your bills or your rent?
If YES, please give the following information:
TYPE OF HELP

5.

HOW OFTEN YOU RECEIVED HELP

AMOUNT OF HELP

SINCE THE DATE ABOVE, have you, or your spouse living with you, earned
money from working or do you expect to earn money from working in the next
14 months? (DO NOT COUNT earnings from self-employment).
If you have earned money from working, please give the following information:
a. Amount(s) of Earning for Past Months:
Gross Wages
Employer's
Name of Worker
Name, Address, and Phone Number

Amount

Dates of
Employment

How Often Paid

From:
To:
From:
To:
Form

SSA-8202-BK (10-2010) EF (10-2010)

Destroy Prior Editions

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5.

b. Estimates of Earnings for this Month and Future Months
Amount

Amount

6.

Month

Month

Month

Month

Month

Month

Month

$

$

$

$

$

$

$

Month

Month

Month

Month

Month

Month

Month

$

$

$

$

$

$

$

SINCE DATE ON PAGE 1, have you, or your spouse living with you, been self-employed
or expect to be self-employed in the current taxable year?
If YES, please give the following information:
Name of SelfEmployed Person

Type of
Income

Last Year's
Gross
Net Income
Income
(or Loss)

This Year's Estimated
Gross
Net Income
Income
(or Loss)

YES

NO

YES

NO

YES

NO

YES

NO

Dates of SelfEmployment
From:
To:
From:
To:

7.

SINCE DATE ON PAGE 1, have you, or your spouse living with you, received any of
the following payments?
• Support (alimony, child support)
• Rental Income
• Interest/dividends (from bank accounts)
• Pensions/Annuities
• Any other cash payments or checks
• Temporary Assistance for Needy Families
(gifts, sick benefits, unemployment, or
• Other
worker's compensation)
DO NOT COUNT — Social Security, SSI, Food Stamps, Federal Civil Service Pensions, Railroad
Retirement, Temporary Assistance for Needy Families or Veterans' Benefits
If you (or your spouse living with you) RECEIVED ANY OF THE PAYMENTS LISTED ABOVE,
please give the following information:
TYPE OF PAYMENT RECEIVED

8.

PAYMENT AMOUNT

HOW OFTEN RECEIVED

a. Do you, or your spouse living with you, have any checking or savings accounts
or any other funds in the bank? Include any accounts where you have direct deposit
of any money.
If YES, please give the following information:
Name and Address of Financial Institution

Type of Account

Account Balance

b. Does your name, or the name of your spouse living with you, appear on any other account
that you do not consider your own? Include any accounts where you have direct deposit of
any money.
If YES, please give the following information:
Name and Address of Financial Institution

Form

SSA-8202-BK (10-2010) EF (10-2010)

Type of Account

Account Balance

PAGE 2

9. Do you, or your spouse living with you, have any cash at home, stocks, bonds, notes, or
certificates of deposit?

YES

NO

YES

NO

YES

NO

YES

NO

If YES, please give the following information:
WHAT YOU HAVE

THE VALUE OF WHAT YOU HAVE

10. Do you, or your spouse living with you, own any land or buildings or does your name appear
on a deed or mortgage of any land or building where YOU DO NOT LIVE?
This includes inherited property, property outside the United States and/or any property your name
is on with other members of your family.
11. SINCE THE DATE ON PAGE 1, have you (or your spouse living with you) sold, transferred title,
disposed of, or given away any money, or other property, including money or property in foreign
countries?
If YES, please give the following information:
WHAT YOU SOLD, TRANSFERRED TITLE,
DISPOSED OF, OR GAVE AWAY

THE VALUE OF THE PROPERTY

12. SINCE THE DATE ON PAGE 1, have you (or your spouse living with you) had any change
in health insurance coverage or other insurance that pays for medical bills?
DO NOT INCLUDE -- Medicare or Medicaid
DO INCLUDE -- Insurance, such as accident, automobile, or casualty if it covers medical bills
for any reason.
IF YOU LIVE IN CALIFORNIA, PLEASE DO NOT ANSWER QUESTION 13 BELOW.
You

13.

Your Spouse

a. Are you currently receiving food stamps?
If YES, go to "b." If NO, go to ''c.''

YES

NO

YES

NO

b. Have you received a recertification notice within the past 30 days?
If YES, go to "e." If NO, go to question 14.

YES

NO

YES

NO

c. Have you filed for food stamps in the last 60 days?
If YES, go to "d." If NO, go to ''e.''

YES

NO

YES

NO

d. Have you received a favorable decision?
If YES, go to question 14. If NO, go to "e."

YES

NO

YES

NO

e. Is everyone in the household applying for or receiving SSI?
If YES go to "f." If NO, go to question 14.

YES

NO

YES

NO

f. May I take your food stamp application today?
If YES, go to question 14. If NO, explain in "g."

YES

NO

YES

NO

g. Explanation

Form

SSA-8202-BK (10-2010) EF (10-2010)

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14. Please answer the following questions:
a. Are you age 62 or older?

YES

NO

b. If you are age 50 or older, are you a widow(er)?

YES

NO

c. If you are age 50 or older and divorced, is your divorced spouse deceased?

YES

NO

d. If you were disabled before age 22, do you have a parent who is age 62 or older,
or disabled, or deceased?

YES

NO

YES

NO

15. SINCE THE DATE ON PAGE 1, has a warrant been issued for your arrest in connection with a
crime, or an attempt to commit a crime, that is a felony (or in New Jersey, a high misdemeanor) or
for violation of a condition of probation or parole under Federal or State law?

If the address where you live is different from the address where you get your mail, please give the address where
you live:
Address (Number, Street, City, State, ZIP Code)

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 11 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. To find the
nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD
21235-0001.
REMARKS

Form

SSA-8202-BK (10-2010) EF (10-2010)

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REMARKS (Continued)

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.
• If you are disabled or blind, you must continue to accept any appropriate vocational rehabilitation services offered
to you by the State agency to which we refer you.
AUTHORIZATIONS/SIGNATURES (Write in Ink)
I/We give permission for the Social Security Administration to check the information I/we have given on this form and
to ask my employer(s) for information about my/our wages.
I/We declare under penalty of perjury that I/we 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/our knowledge.
RECIPIENT SIGNATURE (Write in ink)
Your Signature (First name, middle initial, last name)
Date
Sign
Here
Spouse's Signature (First name, middle initial, last name) (Sign Only if Receiving Date
SSI Payments)
Sign
Here

Area Code and Telephone Number Where
You Can Be Reached

(

)

WITNESSES (Write in ink)
If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign below and give their full names and
addresses.

1. Signature of Witness

2. Signature of Witness

Address (Number, Street, City, State, ZIP Code)

Address (Number, Street, City, State, ZIP Code)

REPRESENTATIVE PAYEE (Write in ink)
Your Title or Relationship to the Recipient

Area Code and Telephone Number
Where You Can Be Reached

(
Your full name (First name, middle initial, last name)

Address (Number, Street, City, State, ZIP Code)

)
Date

Please print here

Please sign here
Form

SSA-8202-BK (10-2010) EF (10-2020)

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KEEP THIS PAGE FOR YOUR RECORDS
NAME

SOCIAL SECURITY NUMBER

NAME

SOCIAL SECURITY NUMBER

/
/

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

(

/

DATE

/

Social Security Office you may visit in person or mail things to:

)

Privacy Act
Statement

You Must
Report
Certain
Changes

See Revised
Privacy Act
Collection and Use of Personal Information
Section 1611(c) of the Social Security Act, and 20 CFR 416.204,
authorizes us to collect this information. The
Statement

information you provide us on this form will be used to determine if you continue to be eligible for supplemental
security income payments.
Completion of this form is voluntary; however, failure to provide all or part of the information could prevent an
accurate and timely decision on your continuing eligibility for benefits.
We rarely use this information you supply for any purpose other than for determining continuing eligibility.
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, audit, or investigative activities necessary to assure the integrity and
improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our
records with records kept by other Federal, State, or local government agencies. Information from these matching
programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is available
on-line at www.socialsecurity.gov or at your local Social Security office.
The amount of your SSI check is based on the information you tell us. To continue getting the right
payment amount, you must report certain changes that happen to you.
You must tell us about changes within 10 days after the month they happen. If you do not report
changes, we may have to take as much as $25, $50, or $100 out of future checks you receive.
You must also report changes in income for your ineligible spouse or children who live with you, or your sponsor or
sponsor's spouse if you are an alien. You must also report if any of these people buy or sell anything of value.
Remember, changes could make your check bigger or smaller. A List of Most of the Changes You Must Report Is
On The Next Page.

How To
Report
Changes

Are You
Working
or Would
You Like
to work

There are several ways you can report changes:
• Call us, toll free, at 1-800-772-1213.
• Call your local Social Security Office at the number above.
• By mail or in person -- see the address above.
If you would like to work or if you are already working and would like to earn more, you should know about SSI
rules known as work incentives. These rules can help you keep your Medicaid and help you keep getting some SSI
even though you are working.
If you want to know more about these rules, call us, toll free, at 1-800-772-1213 or write or visit any Social
Security office.
If you call or visit, ask to speak to someone about work incentives.

Important
Facts About
Food Stamps

Form

You can apply for food stamps at the Social Security Office if you and everyone in your household get or apply for
SSI.
The Social Security Office will help you fill out the food stamp application. You do not have to go to the food stamp
office to apply.

SSA-8202-BK (10-2010) EF (10-2010)

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CHANGES TO REPORT
WHERE YOU LIVE - You must report to Social Security if:
•

You move.

•

You (or your spouse) leave your household for
a calendar month or longer. For example,
you enter a hospital or visit a relative.

•
•
•
•

You leave the United States for 30 days or more.
You enter a jail, prison, or other penal institution.
You are released from a hospital, nursing home, etc.
You are no longer a legal resident of the United States.

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.

•

There are 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.

•
•

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

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).

HELP YOU GET FROM OTHERS - You must report to Social Security if:
•

The amount of help (money, food, clothing, 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 anything of value.

A WARRANT HAS BEEN ISSUED FOR YOUR ARREST - You must report to Social Security if:
•

You flee prosecution or to avoid custody or confinement after conviction for a crime, or an attempt to
commit a crime, which is a felony (or in New Jersey,
a high misdemeanor).

•

You violate a condition of your parole or probation under
Federal or State law.

YOU ARE BLIND OR DISABLED - You must report to Social Security if:
•

Your condition improves or your doctor says you
can return to work.

•

You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22 - You must report to Social Security if:
•

You are under age 18 and live with your parent(s),
ask your parents to report if they have a change in
income, a change in their marriage, a change in the
value of anything they own, or either has a change
in residence.

•

You get married.

•

There are changes in the income, school attendance (if
between the ages of 18 and 21), or marital status of
ineligible children who live in your household.

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES - You must report any
changes to Social Security.
YOU ARE A REPRESENTATIVE PAYEE - You must report to Social Security if:

Form

•

The person for whom you receive SSI checks 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 the person's representative payee.

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