Download:
pdf |
pdf..,
0
SOCIAL SECURITY ADMINISTRATION
/l/t9K!<. -?lP
TEL
~ 0 te:...
;9;::'.1::
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.
0
1
0
Form Approved
OMS No. 0960-0444
Do Not Write in This Space
o
DEFERRED
ABAP
-----....-+-0- - - -
FS-SSA/APP
FS-REFERRED
Filing Date
(Month, Day, Year)
o
o
Receipt
Protective
Preferred Language:
TYPE OF CLAIM
o
Individual
o
Individual with
Ineligible Spouse
o
Couple
o
Child
0
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
5. Spouse's/Parent(s) Name(s)
2. Sex
3. B irthdate
(month, day,
Male
Female
oo
7. B irthdate
6. Sex
Male
8. Social Security Number(s)
(month, day, year)
0
0
4. Social Security Number
year)
Female
I
•
Date of Marriage: (month, day year)
I
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)
Father's Other Social Security Number(s)
.
..
FORM SSA-8001-BK (07/2009) Destroy Pnor EdItions
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).
Your Spouse, if filing
You
la) Are you unable to work because of illnesses,
injuries. or conditions?
DYES
Go to (b)
oGo toNO#13
DYES
Go to (b)
NO
Go to #13
(month, day, year)
(month, day, year)
(b) Enter the date you became unable to work.
0
Go to (c)
Go to (c)
(Brief Description)
(Brief Description)
Ie) What are your illnesses, injuries or conditions?
Go to (d)
Go to (d)
DYES
(d) If you were unable to work because of illnesses,
Provide name(s) and
injuries, or conditions before age 22, do you have a
Social Security
parent who is age 62 or older, unable to work because
Number(s} in Remarks.
of illnesses, injuries, or conditions or deceased?
Goto#13
(e) When did the child become disabled?
(month, day, year)
0
NO
Go to #13
Go to If)
(f) What are the child's disabling illnesses, injuries or conditions?
Go to (g)
(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?
0
YES
Provide namels) and
Social Security
Numberls) in Remarks.
Go to #13
0
NO
Go to #13
i
,
13. If you land your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a),
You
DYES
Go to #17
la) Are you a naturalized United States citizen?
Ib) Are you an American Indian born outside the
United States?
DYES
Go to Ic)
o
NO
Go to (b)
You
NO
Go to (d)
o
Your Spouse, if filing
NO
DYES
Go to #17
Go to Ib)
Your Spouse, if filing
DYES
NO
Go to Id)
Go t-o Ie)
0
0
Ie) Check the block that shows your American Indian status,
Your Spouse, if filing
You
[j
0
0
American Indian born in Canada
Go to #17
Member of a Federally recognized Indian Tribe;
Go to #17
Name of Tribe:
Other American Indian
Explain in Remarks, then Go to Id)
FORM SSA-8001-BK (7/2009)
0
o
0
Page 2
American Indian born in Canada
Go to #17
Member of a Federally recognized Indian Tribe;
Go to #17
Name of Tribe:
Other American indian
Explain in Remarks, then Go to Id)
13. (d) Check the block below that shows your current immigration status.
You
Your Spouse, if filing
D Amerasian Immigrant
Go to #14
D Amerasian Immigrant
Go to #14
D
Go to #14
D Lawful Permanent Resident
Go to #14
D
Lawful Permanent Resident
D
Refugee
Date of entry (month, day, year):
Refugee
Date of entry (month, day, year):
Go to #16
Go to #16
D Asylee
D· Asylee
Date status granted (month, day, year):
Date status granted (month, day, year):
Go to #16
D Conditional Entrant
Date status granted Imonth, day, year):
Goto#16
D Conditional Entrant
Date status granted (month,
d~y,
year):
Go to #16
Go to #16
D
Parolee for One Year
Go to #16
o Parolee for One Year
Go to #16
D
Cuban/Haitian Entrant
Go to #16
D Cuban/Haitian Entrant
Go to #16
o Deportation/Removal Withheld
D Deportation/Removal Withheld
Date Imonth, day, year):
Date (month, day, year):
Go to#16
D
Go to #16
o Other
Other
Explain in Remarks, then Go to (e)
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.
r
Your Spouse, if filing
Imonth, day, year)
You
Imonth, day, year)
(a) Date of Admission:
(b) Was your entry into the United States sponsored
by any person or promoted by an institution or group?
DYES
Go to (c)
·0
NO
Go to Id}
0
D 'NO
Go to '(d)
YES
Go to Ic)
Ic) Give the following information about the person, institution or group:
Name
Address
Telephone Number
)
(
Ie) If filing as an adult, did your parents ever work in
the United States before you were 18?
(f)
(month, day, year)
(month, day, year)
From:
From:
To:
To:
DYES
Go to (t)
oGo toNO#16
Name and Social Security Number of parentis) who worked.
Name
Social Security Number
Name
Social Security Number
FORM SSA-8001-BK (07/2009)
Your Spouse, if filing
You
What was your immigration status, if any, before
adjustment to lawful permanent resident?
(d)
Page 3
DYES
Go to (f)
D
NO
Go to #16
15. (a) Ha~e YOll, your child, or your. parent, been
subjected to battery or extreme cruelty while in 'the
United States?
·You
DYES
Go to Ib)
(b) Have you, your child, or your parent filed a petition DYES
Go to #16
with the Department of Homeland Security for a
change in immigration status because of being
subjected to battery or extreme cruelty?
oGo toNO#17
oGo toNO#17
o
16. Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the
United States?
17. (a) When did you first make your home in the United
YES Explain in
Remarks, then
Go to #17
Go to #17
ONO
(month, day, year)
Your Spouse, if filing
DYES
NO
Go to (b)
Go to #17
0
DYES
Go to #16
oGoto#17
NO
o
o <;;0
YES Explain in
Remarks, then
to #17
NO Go to #17
(month, day, year)
States?
(b) Have you lived outside of the United States since
then?
(c) Give the date(s) of residence outside the United
States.
DYES
Go to (c)
oGo toNO#18
DYES
Go to (c)
(month, day, year)
Date
Left:
o
NO
Go to #18
(month, day, year)
Date
Left:
(month, day, year)
(month, day t 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?
DYES
Go to (b)
(b) Give the date (month, day t year) you left the
United States and the date you returned to the United Date
States.
Left:
oGo toNO#19
o
NO
Go to #19
(month, day, year)
(month, day, year)
Date
Left:
(month, day, year)
Date
Returned:
19. (a) Do you have any unsatisfied felony warrants for
your arrest?
DYES
Go to (b)
(month, day, year)
Date
Returned:
You
0Go toYES
(b)
ONO
Go to #20
(b) In which State or country was the warrant issued? Name of State/Country
Your Spouse, if filing
DYES
NO
Go to (b)
Go to #20
0
Name of State/Country
I
,
Go to (e)
Go to (c)
o
(c) Was the warrant satisfied?
0Go toYES(d)
(d) Date warrant satisfied:
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
o
NO
Go to #20
month, day, year
You
DYES
Go to (b)
DYES
Go to (d)
ONO
Go to #21
Name of State/Country
Your Spouse, if filing
DYES
NO
Go to (b)
Go to #21
o
Name of State/Country
Go to (e)
Go to (c)
(c) Was the warrant satisfied?
DYES
Go to (d)
(d) Date warrant satisfied:
month, day t year
FORM SSA·8001-BK (07/2009)
Page 4
ONO
Go to #21
OVES
Go to (d)
o
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 todi!.Y.)
21. (a) Mark the box that describes where you live.
D
House, Apartment, Mobile Home, Houseboat
D
D
Room in commercial establishment
D
D
Room in private home
D Transient
Noninstitution (rest home, retirement home or
group home)
Institution (hospital, rehabilitation center, prison or
school)
(month, day, year)
(b) Date you began living there:
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.
D
D
Alone
D
Spouse/Parents and/or Children
Other People
PART III - RESOURCES (Show resources as of the first moment of the filing date month. Use
.. tlemarks" to explain any changes.)
23.
I
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--S001-BK (07/2009)
Page 5
0
0
0
0
24. Are there any assets set aside to meet burial expenses Your Answer
for you or your spouse/parentIs)? (If "Yes" describe
the item in "Remarks".)
Spouse's Answer
Mother's Answer
Father's Answer
You
25. la) 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?
(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?
o
DYES
D
NO
D
Your Spouse
NO
YES
YES
YES
DYES
NO
You
DYES
0
0
0
YES
o
NO
NO
NO
DNO
Your Spouse
"¥ES
ONO
IF YOU ANSWERED "YES" TO (a) OR (b). GO TO (el. 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
DO YOU STILL OWN PART OF
THE PROPERTY?
DYES
Item #2
DYES
Item #3
DYES
SOLD ON OPEN MARKET?
Item #1
o
NO
DYES
DYES
DNO
DYES
DYES
DNO
DYES
Item #2
Item #3
FORM SSA-8001-BK (07/2009)
Page 6
o
o
o
o
o
NO
NO
TRADED FOR
GOODS/SERVICES?
GIVEN AWAY?
DYES
DNO
NO
DYES
NO
DYES
NO
DYES
DNO
o
o
NO
NO
New Question #26 :
Do you give us permission to obtain any financial records from any financial institution?
You
Your Spouse, if filing
[] Yes
[] No
[] Yes
[] No
PART IV - INCOME (List all income received since the first moment of the filing date month or
expected in the next 3 months.)
cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect to
76·
List
receive. Include income from wages, sick pay, self-employment, interest, social security, assistance based on
7
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
Amount
Type of Income
Frequency
Received
Date Last
Paid
Source of
Income
$
$
$
$
Jl1.
dl3
(a) Does your spouse/parent pay court ordered child
support?
DYES
0
Go to (b)
Go to #rr.fj~'
NO
fb) Give the amount and frequency of payment:
$
PART V - FOOD STAMPS
2£
'1
fa) Are you currently receiving food stamps?
DYES
Go to (b)
You
D NO
Go to (c)
Your Spouse, if filing
DYES
NO
Go to (c)
Go to (b)
0
o
(b) Have you received a recertification notice within the DYES
Go to (e)
past 30 days?
D NO
Go to #2f!J
3t:.
DYES
Go to (e)
(c) Have you filed for food stamps in the last 60 days? DYES
Go to (d)
D NO
Go to (e)
DYES
Go to (d)
(d) Have you received a favorable decision?
NO
DYES
Go to #'if:!1')c. Go to (e)
o
(e) May I take your food stamp application today?
DYES
NO
DYES
D NO
Go to ~~ Explain in (f) Go to #We,; Explain in If)
DYES
Go to #'i:SJ' 6
NO
Go to #%!?J'
ao
D NO
Go to (e)
o
NO i
Go to (e)
0
(f) Explanation:
PART VI- MISCELLANEOUS
ANSWER #~C.ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISE
GO TO #:;
~
Name of Person Requesting Benefits
Relationship to Claimant
a~
FORM SSA-8001-BK (07/2009)
Page 7
Your Social Security Number
PART VII - REMARKS - Use this space for any explanations.
FORM SSA-8001-BK (07/2009)
Page 8
Insert in Q. 31 under first sentence .
• We hflve asked you for permission to obtain, from flny financial institution, any fimmcia! TecOfd about you
that is held by the institution. We will ask financ.ial institutions for this information whenever we think
it is needed to decide if you are eligible or if you continue to be eligible for 551 benefits. Once authorized,
our permission to contact financial institutions remains in effect until one of the following occurs: {U you or
your spouse notify us in writing that you are canceling your permission, (2) your application for 551 is denied
in fI final decision, (3) your eligibility for 55l terminates, aT (4) we no longer consider your spouse·s income
and reSOUfces to be available to you. If you or your spouse do not give or cancel your permission you may
not be eligible for 55! and we may deny your claim or stop your payments.
PART VIII -- IMPORTANT INFORMATION -- PLEASE' READ CAREFULLY
4(1, The Social Security Administration will check your statements and compare its records with records from other
JI
State and Federal agencies, including the Internal Revenue Service, to make sure you are paid the correct
amount.
PART IX - SIGNATURES
Z'f.
J2.
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.
~, Your Signature (First name, middle initial, last name) (Write in ink.) Date (Month, day, year)
33
SIGN
HERE
T elephona Number(s) where we can contact you
.....
during the day:
(
;w.
31
,
)
-
Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)
SIGN
HERE
.....
~. Applicant's Mailing Address (Number & Street, Apt. No., P.O. Box or Rural Route)
J~
City and State
Enter name of county (if any) in which you
live
ZIP Code
~. Claimant's Residence Address (If different from applicant's mailing address)
3(,
~.
31
Enter name of county lif any) in which you
live
ZIP Code
City and State
If you are blind or visually impaired, check the type of mail you want to receive from us:
D
Certified
0
Regular
D
Regular with a follow-up phone call
WITNESSES
3I'f. 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.
31
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 (07/2009)
Page 9
GlO
u.s. GOVERNMENT PRINTING OFFICE: 200S-349-144111011E
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.
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 (TTY 1-800-325-0778). You may send comments
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.
FORM SSA-8001-BK (01-2008)
Page 10
| File Type | application/pdf |
| File Modified | 2009-09-17 |
| File Created | 2009-09-17 |