SSA-3988 non profi STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR SUP

Form Approved
OMB No. 0960-0643

3988 1

Social Security Administration

STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR
SUPPLEMENTAL SECURITY INCOME PAYMENTS
DRDP:
RUN:
JD:
STC:
WI:
TPI:
FLA:
PROFILE:
DOC:
CFL:
HUN:
FUN:
TMR:
TEL:
LANGPREF:

NAME AND ADDRESS

RETURN THIS FORM WITHIN 30 DAYS FROM RECEIPT
PRINT ANSWERS LIKE THIS ►

Yes

0 1 2 3 4 5 6 7 8 9
Month

Day

Year

0 4

0 1

2 0 0 6

PRINT DATES LIKE THIS ►

No
X

OR LIKE THIS ►

If the mailing address shown above is not correct, provide the correct mailing address
None-N/A

(Number, Street, City, State, and Zip Code):

Street:____________________________________________ Apartment No.__________
________________________________________________________________________
________________________________________________________________________
City:____________________________ State:___________ Zip Code:
YOUR SOCIAL SECURITY NUMBER (SSN):

{Pre-Printed}

SPOUSE’S NAME: {Pre-Printed}
SOCIAL SECURITY NUMBER (SSN):

{Pre-Printed}

BECAUSE YOU ARE THE REPRESENTATIVE PAYEE, YOU MUST ANSWER THE FOLLOWING
QUESTIONS AS IF {recipient’s name} WERE COMPLETING THE FORM.
1.

What is your current marital status?
Married living with Spouse

Married NOT living with Spouse

Divorced

Widowed

Single

Does this represent a change in your marital status since {Pre-Printed}?
If the answer to the question is “no,” go to Question 2.
If the answer to the question is “yes,” please give the date that your marital status changed.
(Month/Year)

Yes

No

3988 2
2.

Since {Pre-Printed}, has anyone moved into or out of your residence? (include births and
deaths)

Yes

No

If the answer is “yes,” complete the information below:
a. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Child

Date Moved In

None-N/A

Other Relative

Other ___________________

Date Moved Out

b. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Child

Date Moved In

None-N/A

Other Relative

Other ___________________

Date Moved Out

c. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Child

Date Moved In
3.

None-N/A

Other Relative

Other ___________________

Date Moved Out
Yes

Since {Pre-Printed}, have you lived at a different address?

No

If the answer to the question is “yes,” give the new address:
ADDRESS (Number, Street, City, State, and Zip Code):

None-N/A

Street:____________________________________________ Apartment No.__________
________________________________________________________________________
________________________________________________________________________
City:____________________________ State:___________ Zip Code:
Date You Moved (Month/Year)
4.

Yes

Does anyone live in the same household with you?

No

If “yes,” list all the people who live in the same household with you.
a. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Child

Other Relative

b. Name:____________________________________________

Date of Birth

Other ___________________

Social Security Number

Date of Birth

Relationship:

None-N/A

Spouse

Mother

Father

Child

Other Relative

None-N/A
Other ___________________

Social Security Number

Question continues on the next page

3988 3
c. Name:____________________________________________
Relationship:

Spouse

Mother

Father

Child

Other Relative

d. Name:____________________________________________
Spouse

Mother

Father

Child

Other Relative

None-N/A
Other ___________________

Social Security Number

Date of Birth

e. Name:____________________________________________
Relationship:

Other ___________________

Social Security Number

Date of Birth

Relationship:

None-N/A

Spouse

Mother

Father

Date of Birth

Child

Other Relative

None-N/A
Other ___________________

Social Security Number

If you need more space use the REMARKS Section on page 10.
5.

Do all of the people who live with you receive public assistance payments?

Yes

No

(For example: welfare, VA pension, general assistance, and SSI.)
6.

Since {Pre-Printed}, did anyone who was NOT LIVING WITH YOU:

Yes No

Give you a free place to live?

Help you pay the mortgage, rent, property insurance, property
taxes, and/or sewer charges?

Give you or help you pay for food, gas, electricity, heating
fuel, water, and/or garbage collection service?

Give you any other financial help?
If the answer to all 4 of the questions is “no,” go to Question 7.
If the answer to any of the 4 questions is “yes,” please explain assistance received:
______________________________________________________________________________________
______________________________________________________________________________________
7.

______________________________________________________________________________________
Since {Pre-Printed}, have you or your spouse living with you been in a hospital, nursing home,
Yes No
jail or prison, or other institution for a full calendar month or longer? (A “full calendar
month” means, for example, from December 1 through December 31.)
If the answer to the question is “no,” go to Question 8.
If the answer to the question is “yes”, please give:
Question continues on the next page

3988 4
You

Date Entered
(Month/Day/Year)

Your
Spouse

Date Discharged
(Month/Day/Year)

a.
Hospital

a.
Nursing Home

Jail

Other Institution __________________________

None-N/A

Name and Address of Institution: __________________________________________________________

________________________________________________________________________________
b.
Hospital

b.
Nursing Home

Jail

Other Institution __________________________

None-N/A

Name and Address of Institution: __________________________________________________________

________________________________________________________________________________
c.
Hospital

c.
Nursing Home

Jail

Other Institution __________________________

None-N/A

Name and Address of Institution: __________________________________________________________

________________________________________________________________________________
d.
Hospital

d.
Nursing Home

Jail

Other Institution __________________________

None-N/A

Name and Address of Institution: __________________________________________________________

________________________________________________________________________________
8.

Since {Pre-Printed}, have you or your spouse living with you been outside the United States
(the 50 States, District of Columbia, and the Northern Mariana Islands) for more than 30
days in a row?

Yes

No

If the answer to the question is “no,” go to Question 9.
If the answer to the question is “yes,” please give:
You

Date(s) Left
(Month/Day/Year)

Your
Spouse

Date(s) Returned
(Month/Day/Year)

Where Did You OR Your Spouse,
Go?

_______________________ N/A
a.

a.

b.

b.

c.

c.

d.

d.

_______________________
_______________________ N/A
_______________________
_______________________ N/A
_______________________
_______________________ N/A
_______________________

3988 5
9.

Yes No

Since {Pre-Printed}, have you or your spouse living with you worked?

Are you or your spouse living with you currently working?

Do you or your spouse living with you expect to work in the next 14 months?
If the answer to all 3 of the questions is “no,” go to question 10.
If the answer to any of the 3 questions is “yes,” please complete the following:
Example: If you have $600, it would be printed
like this. SHOW DOLLARS ONLY

You

Your
Spouse

Name of Employer/
Address
____________________
____________________

Amount:
Paid:

$

Amount:
Paid:

,

Weekly

Amount: $
____________________ Paid: Weekly

____________________

6 0 0

Gross Wages
(Before Any Deductions)

____________________

____________________

,

$

$

,

From:

Monthly

,

Monthly

To:
From:

.
BiWeekly

To:
From:

.
BiWeekly

Weekly

Dates of Employment
(Month/Day/Year)

.
BiWeekly

.

Monthly

To:

Are you a student?

Yes

No

Yes

No

Birth Date: {Pre-Printed}
10.

Since {Pre-Printed}, have you or your spouse living with you been self-employed or do you or
your spouse living with you expect to be self-employed in the current taxable year?
If the answer to the question is “no,” go to Question 11.
If the answer to the question is “yes,” please give:
You
Type of Business

N/A

Your Spouse

N/A

___________________ ____________________
___________________ ____________________

Total Gross Income for Last Year

$

Net Income for Last Year

$

Estimated Gross Income for this Year

$

Estimated Net Income for this Year

$

,
,
,
,

.
.
.
.

$
$
$
$

,
,
,
,

.
.
.
.

3988 6
11.

Since {Pre-Printed}, have you or your spouse living with you received, or do you expect to
receive in the next 14 months, any of the income listed below:

Yes No

A. Private pensions or annuities (do not include Social Security, SSI, or food
stamps)?
B. Unemployment or worker’s compensation?
C. Welfare or State or local assistance based on need?
D. Veterans Administration benefits (based on need, not based on need, education)?
E. Railroad Board, Black Lung, Military or Civil Service pensions?
F. Rental/lease income?
G. Alimony or child support?
H. Dividends or royalties?
I. Interest earned on money in bank accounts (including interest in checking account)?
J. Money from a trust fund?
K. Money from any other person or organization?
L. Any other income not included above?
If the answer to all 12 of the questions is “no,” go to Question 12.
If the answer to any of the 12 questions is “yes,” tell us about that item. Please give:
Type of
Income

Received by
Amount/How Often
(use whole dollars)

(choose
Your
from letters
You
above)
Spouse

$

,

Weekly

$
Weekly

Dates Received or Expected

.
BiWeekly

,

Monthly

.
BiWeekly

Monthly

From:

Source
(Name/Address of Person, Bank,
Company or Organization)

_____________________ N/A
_____________________

To:
From:

_____________________
_____________________ N/A
_____________________

To:

_____________________
Question continues on the next page

3988 7
Type of
Income

Received by
Amount /
How Often

Your
(choose from
You
letters above)
Spouse

$

,

Weekly

$

,

Weekly

$
Weekly

.
BiWeekly

Monthly

.
BiWeekly

,

Monthly

.
BiWeekly

Source
(Name/Address of Person, Bank,
Company or Organization)

Dates Received or Expected

Monthly

_____________________ N/A

From:

_____________________
_____________________

To:

_____________________ N/A

From:

_____________________
_____________________

To:

_____________________ N/A

From:

_____________________
_____________________

To:

12.

Do you or your spouse living with you have your SSI check sent directly to a
bank or other financial institution? (This is known as “Direct Deposit”)

13.

Do you or your spouse living with you own any of the following items?

You:
Yes No

Answer “Yes”, if your name or your spouse’s name appears alone or with any other person
as the owner or part owner for any of these items:

Your
Spouse:
Yes No

Yes No

A. Cash (with you, at home, or in a safe deposit box)?
B. Checking or savings accounts?
C. Money market accounts?
D. Credit union accounts?
E. Christmas club accounts?
F. Savings certificates/certificates of deposit?
G. Promissory notes or IOU’s?
H. Stocks, bonds or U.S. Savings Bonds?
I. Trusts?
Question continues on the next page

3988 8
If the answer to all 9 of the questions is “no,” go to Question 14.
If the answer to any of the 9 questions is “yes,” please give:

Total Value of Each

Name and Address of Bank, Company or Organization

Other

You

(choose
from
letters
above)

Your Spouse

Name of Owner or
Each Co-Owner
Item

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

,

$

.

__________________________________________________ N/A
__________________________________________________

Account Number:

Do you or your spouse living with you own, or partially own, or are you buying any real
estate (land or buildings or other structures on the land)? (Include property outside the U.S.,
inherited property, and life estates. Do not include the home you live in.)

14.

Yes

No

If the answer to the question is “no,” go to Question 15.
If the answer to the question is “yes,” please give:

Estimated Current
Market Value

Tax Assessed Value, if
known

Amount of Mortgage
Payment, if any

Amount Owed on this
Property

Other

Your Spouse

You

Owner or
Co-Owner

$
$

,
,

.$
.$

,
,

.$
.$

,
,

.$
.$

,
,

Description (Include type and size of structures, acreage or lot size, and location of property)
N/A
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Question continues on the next page

.
.

3988 9
Use (Describe how the property is used. If not in use, give date of last use and next planned use.)

N/A

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
15.

Since {Pre-Printed}, have you or your spouse living with you had any change in
health insurance coverage or other insurance that pays for medical bills?

You:
Yes No

Your
Spouse:
Yes No

(Do not include Medicare, but do include insurance such as accident, automobile,
or casualty if it covers medical bills for any reason.)
If the answer to the question is “no,” go to Question 16.
If the answer to the question is “yes,” please explain:

None-N/A

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
16.

You:
Yes No
a. Are you age 62 or older?
b. If you are age 50 or older, are you a widow(er)?
c. If you are age 50 or older and divorced, is your divorced
spouse deceased?
d. Were you disabled before age 22?
e. Do you have a parent who is age 62 or older, disabled, or
deceased?

17.

a. Which language do you prefer to use when speaking to us?
English

Spanish

Other (write in name of language): ___________________________

b. Which language do you prefer that we use to write to you?
English

Spanish

Other (write in name of language): ___________________________

Your
Spouse:
Yes No

3988 10
WE ARE REQUIRED BY LAW TO ASK THE FOLLOWING QUESTIONS OF ALL SSI RECIPIENTS

18.

You:
Yes No

Your Spouse:
Yes No

Name of State/Country

Name of State/Country

a. Do you have any unsatisfied felony
warrants for your arrest?
b. In which state or country was the warrant
issued?
c. Was the warrant satisfied?

Yes

No

Yes

No

Yes

No

Yes

No

d. Date warrant satisfied
19.

a. Do you have any unsatisfied Federal or
State warrants for violating the conditions
of probation or parole?
b. In which state or country was the warrant
issued?

Name of State/Country

c. Was the warrant satisfied?

Yes

Name of State/Country

No

Yes

No

d. Date warrant satisfied
20.

a. Since {Pre-Printed}, have you or your spouse living with you sold, transferred title,
disposed of or given away any property including property in foreign countries?

Yes

No

Yes

No

b. Since {Pre-Printed}, have you or your spouse living with you disposed of or given away any
money?
If money was given away, please give amount: $

,

21.
a. Have you used any medical care or services in the past 12 months
that was paid for by Medicaid (or Medi-Cal, etc.)?

.

b. Do you expect to receive any medical care or service in the next 12
months that will be paid for by Medicaid (or Medi-Cal, etc.)?
c. Without Medicaid (or Medi-Cal, etc.), would you be unable to pay
your medical bills if you became ill or injured in the next 12 months?
REMARKS:______________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

3988 11
YOUR AUTHORIZATION
I give my permission for the Social Security Administration to check the information I have given on this form, and to ask my
employer(s) for information about my wages. I understand that the Social Security Administration will compare its records with
records from other State and Federal agencies to make sure I am paid the correct amount of benefits. 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 or misleading statement about a material fact in this
information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURES (Write in ink)
Your Signature (First name, middle initial, last name)
SIGN
HERE _____________________________________________

DATE:

Area Code & Telephone Number (Where you can be reached)

(

)

None

Spouse’s Signature

(First name, middle initial, last name) (Sign only if
spouse is also receiving SSI payments)

SIGN
HERE _____________________________________________

DATE:

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 and Zip Code)

Address (Number, Street, City, State and Zip Code)

REPRESENTATIVE PAYEE (Write in ink)
If you are the Representative Payee and are filing this statement on behalf of another person give:
Your Full Name (First name, middle initial, last name)

Your Title or Relationship to the Recipient

Address (Number, Street, City, State, and Zip Code)

Your Social Security Number

Area Code & Telephone Number (Where you can be reached)

(

)
WBDOC

None
WBDOC1

WBDOC2

FOR SSA USE ONLY
WBDOC3
FO UND

FO1 DEC

FO2

FO3