Form SSA-8001-BK Application For Supplemental Security Income

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0444
Do Not Write in This Space

TEL

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME

I am/We are applying 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 Social
Security Administration, and where applicable, for
medical assistance under Title XIX of the Social
Security Act.

DEFERRED

ABAP

FS-SSA/APP

FS-REFERRED

Filing Date
(Month, Day, Year)

Receipt

Protective

Preferred Language:

TYPE OF CLAIM

Individual

Individual with
Ineligible Spouse

Couple

Child

Child with Parents

PART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment of
the filing date month.
1. First Name, Middle Initial, Last Name

2. Sex
3. Birthdate
(month, day, year)
Male
Female

5. Spouse's/Parent(s) Name(s)

6. Sex
Male

7. Birthdate

(month, day, year)

4. Social Security Number

8. Social Security Number(s)

Female
Date of Marriage: (month, day, year)

9.

Other Name(s) and Social Security Number(s) you, your spouse/parents used:
(a) Your Other Name(s) (including Maiden Name)

Your Other Social Security Number(s)

(b) Spouse's/Mother's Other Name(s) (including Maiden Name) Spouse's/Mother's Other Social Security
Number(s)

(c) Father's Other Name(s)

FORM SSA-8001-BK (01/2008) Destroy Prior Editions

Father's Other Social Security Number(s)

Page 1

10. Your Place of Birth (City and State or Foreign Country)

11. Spouse's Place of Birth (City and State or Foreign Country)

12. If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
You

(a) Are you unable to work because of illnesses,
injuries, or conditions?

YES
Go to (b)

Your Spouse, if filing

NO
Go to #13

(month, day, year)

(b) Enter the date you became unable to work

YES
Go to (b)

NO
Go to #13

(month, day, year)

Go to (c)
(c) What are your illnesses, injuries or conditions?

(Brief Description)

Go to (c)
(Brief Description)

Go to (d)
YES
Provide name(s) and
Social Security
Number(s) in Remarks.
Go to #13
(month, day, year)

(d) If you were unable to work because of illnesses,
injuries, or conditions before age 22, do you have a
parent who is age 62 or older, unable to work because
of illnesses, injuries, or conditions or deceased?
(e) When did the child become disabled?

Go to (d)
NO
Go to #13

Go to (f)
(f) What are the child's disabling illnesses, injuries or conditions?

Go to (g)
YES
Provide name(s) and
Social Security
Number(s) in Remarks.
Go to #13

(g) Does the child have a parent or stepparent who is
62 or older, unable to work because of illnesses,
injuries, or conditions, or deceased?

13.

NO
Go to #13

If you (and your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a).
You
YES
Go to #17

(a) Are you a naturalized United States citizen?
(b) Are you an American Indian born outside the
United States?

YES
Go to (c)

NO
Go to (b)
You
NO
Go to (d)

Your Spouse, if filing
YES
NO
Go to #17
Go to (b)
Your Spouse, if filing
YES
NO
Go to (c)
Go to (d)

(c) Check the block that shows your American Indian status.
You
American Indian born in Canada

Your Spouse, if filing
Go to #17

Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17
Other American Indian
Explain in Remarks, then Go to (d)
FORM SSA-8001-BK (01/2008)

American Indian born in Canada

Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17
Other American Indian
Explain in Remarks, then Go to (d)

Page 2

Go to #17

13. (d) Check the block below that shows your current immigration status.
You

Your Spouse, if filing

Amerasian Immigrant

Go to #14

Amerasian Immigrant

Go to #14

Lawful Permanent Resident

Go to #14

Lawful Permanent Resident

Go to #14

Refugee
Date of entry (month, day, year):

Refugee
Date of entry (month, day, year):

Go to #16

Asylee
Date status granted (month, day, year):
Conditional Entrant
Date status granted (month, day, year):

Go to #16

Asylee
Date status granted (month, day, year):

Go to #16

Conditional Entrant
Date status granted (month, day, year):

Go to #16

Go to #16

Go to #16

Parolee for One Year

Go to #16

Parolee for One Year

Go to #16

Cuban/Haitian Entrant

Go to #16

Cuban/Haitian Entrant

Go to #16

Deportation/Removal Withheld
Date (month, day, year):

Deportation/Removal Withheld
Date (month, day, year):

Go to #16

Other
Explain in Remarks, then Go to (e)

Go to #16

Other
Explain in Remarks, then Go to (e)

(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United States
citizen, or a lawfully admitted permanent resident, Go to #15; otherwise Go to #17.
14.

You

Your Spouse, if filing

(month, day, year)

(a) Date of Admission:

YES
(b) Was your entry into the United States sponsored
by any person or promoted by an institution or group? Go to (c)

NO
Go to (d)

(month, day, year)

YES
Go to (c)

NO
Go to (d)

(c) Give the following information about the person, institution or group:
Name

Address

Telephone Number

(
You

(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?

(e) If filing as an adult, did your parents ever work in
the United States before you were 18?

Your Spouse, if filing

(month, day, year)

(month, day, year)

From:

From:

To:

To:

YES
Go to (f)

NO
Go to #16

(f) Name and Social Security Number of parent(s) who worked.
Name

Social Security Number

Name

Social Security Number

FORM SSA-8001-BK (01/2008)

)

Page 3

YES
Go to (f)

NO
Go to #16

15. (a) Have you, your child, or your parent, been
subjected to battery or extreme cruelty while in the
United States?
(b) Have you, your child, or your parent filed a
petition with the Department of Homeland Security
for a change in immigration status because of being
subjected to battery or extreme cruelty?

YES
Go to (b)

You
NO
Go to #17

Your Spouse, if filing
YES
NO
Go to (b)
Go to #17

YES
Go to #16

NO
Go to #17

YES
Go to #16

16. Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the
United States?

YES Explain in
Remarks, then
Go to #17
NO Go to #17
(month, day, year)

17. (a) When did you first make your home in the United
States?
(b) Have you lived outside of the United States since
then?
(c) Give the date(s) of residence outside the United
States.

YES
Go to (c)
Date
Left:

NO
Go to #18

(month, day, year)

NO
Go to #17

YES Explain in
Remarks, then
Go to #17
NO Go to #17
(month, day, year)

YES
Go to (c)
Date
Left:

NO
Go to #18

(month, day, year)

(month, day, year)
(month, day, year)
Date
Date
Returned:
Returned:
18. (a) Have you been outside the United States (the 50
States, District of Columbia and Northern Mariana
Islands) 30 days prior to the filing date?

YES
Go to (b)

(b) Give the date (month, day, year) you left the
United States and the date you returned to the United Date
States.
Left:

NO
Go to #19

(month, day, year)

(month, day, year)

Date
Returned:
19. (a) Do you have any unsatisfied felony warrants for
your arrest?
(b) In which State or country was the warrant
issued?

YES
Go to (b)

YES
Go to (b)

NO
Go to #19

(month, day, year)
Date
Left:

(month, day, year)

Date
Returned:
You

NO
Go to #20

Name of State/Country

Your Spouse, if filing
YES
NO
Go to (b)
Go to #20
Name of State/Country

Go to (c)
(c) Was the warrant satisfied?

YES
Go to (d)

(d) Date warrant satisfied:

YES
Go to (b)

Name of State/Country

Go to (c)
YES
Go to (d)

FORM SSA-8001-BK (01/2008)

NO
Go to #20

Your Spouse, if filing
NO
YES
NO
Go to #21 Go to (b)
Go to #21

Name of State/Country

(c) Was the warrant satisfied?
(d) Date warrant satisfied:

You

YES
Go to (d)

month, day, year

month, day, year

20. (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?

NO
Go to #20

Go to (c)

NO
Go to #21

month, day, year
Page 4

Go to (c)
YES
Go to (d)

NO
Go to #21

month, day, year

PART II LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first
moment of the filing date month and today.)
21. (a) Mark the box that describes where you live.
House, Apartment, Mobile Home, Houseboat

Noninstitution (rest home, retirement home or
group home)

Room in commercial establishment

Institution (hospital, rehabilitation center, prison or
school)

Room in private home

Transient

(b) Date you began living there:

(month, day, year)

22. Mark the box that describes with whom you live. If you live in a foster home, group home, or an institution, or
if you are a transient, do not answer but explain in remarks.
Alone

Spouse/Parents and/or Children

Other People

PART III - RESOURCES (Show resources as of the first moment of the filing date month. Use
"Remarks" to explain any changes.)
23.

If you own, or your name or your spouse's/parent's name(s) appear on any of the following items (either alone
or with other people's name(s)), enter the total cash value of item(s) on each line.

YES NO

Description of Items
Marked YES

Co-owned
With Others
Yes
No

Dollar Value
Spouse or
Parents Own

Dollar Value
You Own

a. Vehicles (cars, trucks,
boats, motorcycles).
How many?

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

b. Insurance policies

c. Cash at home, with
you, or anywhere else
d. Savings, checking
accounts, stocks, bonds
e. Trust(s)

f. Property other than the
home you live in
g. Life estates or
property you inherited
h. Other items that can
be turned into cash
FORM SSA-8001-BK (01/2008)

Page 5

24. Are there any assets set aside to meet burial expenses Your Answer
for you or your spouse/parent(s)? (If "Yes" describe
Spouse's Answer
the item in "Remarks".)

YES

NO

YES

NO

Mother's Answer

YES

NO

Father's Answer

YES

NO

25. (a) Have you or your spouse sold, transferred title,
disposed of or given away, any money or other
property, including money or property in foreign
countries, since the first moment of the filing date
month or within the 36 months prior to the filing date
month?

You
YES

Your Spouse
NO

YES

You

(b) If you co-owned any money or property with
another person(s), did you or any co-owner sell,
transfer, or give away any co-owned money or
property within the 36 months prior to the filing date
month?

YES

NO

Your Spouse
NO

YES

NO

IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #26.
(c)

OWNER'S/CO-OWNER'S NAME

DESCRIPTION OF PROPERTY

DATE OF DISPOSAL

NAME AND ADDRESS OF
PURCHASER OR RECIPIENT

RELATIONSHIP TO OWNER

VALUE OF PROPERTY AND/OR
AMOUNT OF CASH GIFT

Item#1
Item #2
Item #3

Item #1

$

Item #2

$

Item #3

$
SALE PRICE OR OTHER
CONSIDERATION

ARE OTHER CONSIDERATIONS OR

PROCEEDS EXPECTED? EXPLAIN

Item #1
Item #2
Item #3
SOLD ON OPEN MARKET?
Item #1
Item #2
Item #3

GIVEN AWAY?

DO YOU STILL OWN PART OF
THE PROPERTY?
YES

NO

YES

NO

YES

NO

TRADED FOR
GOODS/SERVICES?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

FORM SSA-8001-BK (01/2008)

Page 6

PART IV - INCOME (List all income received since the first moment of the filing date month or
expected in the next 3 months.)
26. List cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect to
receive. Include income from wages, sick pay, self-employment, interest, social security, assistance based on
need, VA, gifts, pensions, and any other type of income. Give date last paid if income will stop in the next 3
months. Also note here if anyone pays any bills for you directly or gives you money to pay them.
Person Receiving
Income

Type of Income

Amount

Frequency
Received

Date Last
Paid

YES

NO

Source of
Income

$
$
$
$
27. (a) Does your spouse/parent pay court ordered child
support?

Go to (b)

Go to #28

(b) Give the amount and frequency of payment:

$
PART V - FOOD STAMPS
YES
Go to (b)

You
NO
Go to (c)

Your Spouse, if filing
YES
NO
Go to (b)
Go to (c)

(b) Have you received a recertification notice within
the past 30 days?

YES
Go to (e)

NO
Go to #29

YES
Go to (e)

NO
Go to #29

(c) Have you filed for food stamps in the last 60 days?

YES
Go to (d)

NO
Go to (e)

YES
Go to (d)

NO
Go to (e)

(d) Have you received a favorable decision?

YES
Go to #29

NO
Go to (e)

YES
Go to #29

NO
Go to (e)

(e) May I take your food stamp application today?

YES
Go to #29

NO
YES
Explain in (f) Go to #29

28. (a) Are you currently receiving food stamps?

NO
Explain in (f)

(f) Explanation:

PART VI- MISCELLANEOUS
ANSWER #29 ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISE
G0 T0 #30.
29. Name of Person Requesting Benefits

FORM SSA-8001-BK (01/2008)

Relationship to Claimant

Page 7

Your Social Security Number

PART VII - REMARKS - Use this space for any explanations.

FORM SSA-8001-BK (01/2008)

Page 8

PART VIII -- IMPORTANT INFORMATION -- PLEASE READ CAREFULLY
30. 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 you are paid the correct
amount.

PART IX - SIGNATURES
31. 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 false information, or causes someone else to do so, commits a crime and may be
sent to prison, or may face other penalties, or both.
32. Your Signature (First name, middle initial, last name) (Write in ink.) Date (Month, day, year)

SIGN
HERE

Telephone Number(s) where we can contact you
during the day:

(

)

-

33. Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)

SIGN
HERE
34. Applicant's Mailing Address (Number & Street, Apt. No., P.O. Box or Rural Route)

City and State

ZIP Code

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

35. Claimant's Residence Address (If different from applicant's mailing address)

City and State

ZIP Code

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

36. If you are blind, check the type of mail you want to receive from us:
Certified

Regular

Regular with a follow-up phone call

WITNESSES
37. Your application does not ordinarily 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 address.
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-8001-BK (01/2008)

Page 9

RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOME
Name

Social Security Number

Date

Name

Social Security Number

Date

If you have a question or something to report call:

(

)

Social Security Office you may visit or write to:

-

Your application for Supplemental Security Income will be processed as quickly as possible. You should hear from
us within _____days. If you do not hear from us within that time, please get in touch with us in person, by mail, or
call us at the telephone number shown at the top of this page.
We may need more information before we can decide whether or not you are eligible for SSI payments. If we need
more information, we will contact you. In the meantime, if you move or change your mailing address, you (or
someone for you) should report the change to the office shown at the top of this page.
You (or someone for you) must let us know if your immigration status changes.
Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. You
could lose some SSI payments if you do not let us know right away.
Always give your Social Security Number when writing or telephoning about your claim. If you have any questions
about your claim, we will be glad to help you.

PRIVACY/PAPERWORK ACT NOTICE
Section 1631(e) of the Social Security Act authorizes the collection of information requested on this form. The
information you provide will be used to enable the Social Security Administration to determine if you are eligible for
Supplemental Security Income payments. You do not have to give us the information requested. However, if you
do not provide the information, we will be unable to make an accurate and timely decision on your claim which may
result in loss of some payments. We may provide information collected on this form to another Federal, State, or
local government agency to assist us in determining your eligibility for SSI payments or if a Federal law requires the
release of information.
We may also use the information you give us when we match records by computer. Matching programs compare
our records with those of other Federal, State, or local government agencies and financial institutions. Many
agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available
in Social Security offices. If you want to learn more about this, contact any Social Security office.

See Revised Privacy Act Notice
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
18-19 minutes to read the instructions, gather the facts, and answer the questions. SEND 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. 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. See Revised Paperwork

Reduction Act Statement
FORM SSA-8001-BK (01/2008)

Page 10

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to enable the Social Security
Administration to determine if you are eligible for Supplemental Security Income (SSI)
payments.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may keep us from making an accurate and timely decision on your
claim, which in turn may result in loss of some payments.
We rarely use the information you supply for any purpose other than for determining
eligibility for SSI. 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 and audit activities necessary to assure the
integrity and improvement of Social Security programs (e.g., to the Bureau of
the Census and private concerns under contract to Social Security).
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.
Complete lists of routine uses for this information are available in System of Records
Notice 60-0103, Supplemental Security Income Record and Special Veterans Benefits,
and also in System of Records Notice 60-0089, Claims Folder Systems. The Notices,

additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.ssa.gov or at your local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 18
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.