SSA-8010-BK Statement of Income and Resources

Form Approved
OMB No. 0960-0124

SOCIAL SECURITY ADMINISTRATION

D.O. Use

STATEMENT OF INCOME AND RESOURCES

Name of Applicant/Recipient

I am/We are providing this statement on behalf of
to determine his/her eligibility 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.

Social Security Number

/

/

Filing Date
MM
DD
YY
Date of Last Determination
MM
DD
YY

OR

PERSONS REPORTING INCOME AND/OR RESOURCES
First Name, Middle Initial, Last Name

Spouse's Name (First, middle initial, last)

Social Security Number

Social Security Number

/

/

Check Which:
Sponsor

/
Ineligible Child
Essential Person

Parent

/

Check Which: (Spouse of)
Sponsor
Parent

1. PUBLIC INCOME MAINTENANCE PAYMENTS (Governmental

You

Assistance Based on Need)

YES

(a) Have you received any of the public income maintenance
payments listed in (b) below since the first moment of the
filing date month or the last determination, or do you expect
to receive them in any of the next 14 months?

Go to (b)

Your Spouse
YES

NO

Go to #3 Go to (b)

NO

Go to #3

(b) Give the following information about the payments:
TYPE
Supplemental
Security Income

PERIOD
EXPECTED
REC'D HOW
COVERED
RECEIPT
AMOUNT
BY
OFTEN BY INCOME DATE*
You

Your
Spouse
State or Local GovYou

$

Monthly

$
>

$

>

$

>

$

>

Aid to Families with You
Dependent Children Your

$

>

$

>

General Assistance
from the Bureau of
Your
Indian Affairs
Spouse

$

>

$

>

ernment Assistance Your
Based on Need
Spouse
Refugee Assistance You
Payments Based on Your
Need
Spouse

Spouse
You

Veterans Benefits
Based on Need

You

SOURCE

Social Security
Administration

$

Disaster Relief

IDENTIFICATION
NUMBER

Bureau of Indian
Affairs

$

Your
Spouse
You

$
Dept. of
Veterans Affairs

$

Your
Spouse

$

* If you are not receiving this income this month but expect it, enter the date you think you will receive it.
> If your share of the grant is unknown, enter the amount of the monthly family grant.
2. OTHER INCOME YOU RECEIVED WHILE RECEIVING PUBLIC

INCOME MAINTENANCE PAYMENTS

You

Your Spouse

YES
NO
YES
NO
(a) Have you received any other income in addition to any public income
Go to (b) Go to #6 Go to (b) Go to #6
maintenance payments shown in #1?
Form SSA-8010-BK (05-2010) EF (05-2010)
Destroy Prior Editions

Page 1

2. (b)
(Cont)

If you are:
• The sponsor of an alien
• The spouse of a sponsor
• An essential person

Then:
Answer questions 3, 4 and 5 about your other income.

• A parent
• The spouse of a parent

If you have received these public income maintenance payments
continuously since the date shown on page 1 AND you expect to
continue receiving these payments this month and for the next 14
months, go to #6; OTHERWISE, go to #3.

• An ineligible child

If you have received and expect to continue receiving these
public income maintenance payments as described above,
go to #17; OTHERWISE, go to #3.

3. (a) Have you received wages since the first moment of

the filing date month or since the last
determination?

You
YES
Go to (b)

NO
Go to (d)

Your Spouse
YES
NO
Go to (b)

Go to (d)

(b)Name and Address of Employer (include telephone number and area code, if known)
You
Your Spouse

(c) Total wages received (before any deductions) for each month:
Month(s)

You

Amounts
Month(s)

Your
Spouse

Amounts

(d)Do you expect to receive any wages in the next
14 months?

You
YES
Go to (e)

NO
Go to #4

Your Spouse
YES
NO
Go to (e)

Go to #4

(e) Name and address of employer if different from 3(b) (include telephone number and area code, if known)
You
Your Spouse

(f) Give the following information:
RATE OF PAY

You

$

per

Your
Spouse $

per

AMOUNT WORKED PER
PAY PERIOD

(g)Do you expect any change in wage information
provided in 3(f)?
(h)Explain change:
You

Form SSA-8010-BK (05-2010) EF (05-2010)

HOW OFTEN
PAID

You
YES
Go to (h)

Your Spouse

Page 2

PAY DAY OR
DATE PAID

NO
Go to #4

DATE LAST PAID
(Month, day, year)

Your Spouse
YES
NO
Go to (h)

Go to #4

4. (a) Have you been self-employed at any time since the

You
beginning of the taxable year in which the filing date
YES
NO
month or the last determination occurs or do you
Go to #5
expect to be self-employed in the current taxable year? Go to (b)
(b)Give the following information:
TYPE OF BUSINESS

You

Your
Spouse

GROSS
INCOME

LAST YEAR'S:
NET
INCOME
LOSS

GROSS
INCOME

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

mination, have you received or do you expect to receive income
in the next 14 months from any of the following sources?

FEDERAL BENEFITS:
Social Security
Railroad Retirement
Veterans Affairs Benefits Not Based on Need
Office of Personnel Management (Civil Service)
Military Pension, Special Pay, or Allowance
Black Lung
Earned Income Tax Credits
STATE/LOCAL BENEFITS:
Unemployment Compensation
Worker's Compensation
State Disability
State or Local Pension
PRIVATE BENEFITS:
Employer or Union Pension
Insurance or Annuity Payments
Private Needs-Based Assistance
MISCELLANEOUS:
Interest (bank accounts, stocks, CD's, etc.)
Rental/Lease Income
Dividends/Royalties
Alimony/Cash Support
Child Support
OTHER INCOME NOT PREVIOUSLY MENTIONED:

Form SSA-8010-BK (05-2010) EF (05-2010)

Page 3

You
YES

Go to (b)

THIS YEAR'S:
NET
INCOME
LOSS

$

5. (a) Since the first moment of the filing date month or the last deter-

Your Spouse
YES
NO
Go to #5

DATES OF SELFEMPLOYMENT

Your Spouse
NO

YES

NO

5. (b)Give the following information for any "Yes" answer in 5(a); otherwise go to #6.
(Cont)

PERSON
RECEIVING

TYPE OF
INCOME

AMOUNT

FREQUENCY

DATES EXPECTED
OR RECEIVED

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

IDENTIFYING
NUMBER

From:

You

$

To:
From:

You

$

To:
From:

You

$

To:
From:

Your
Spouse

$

To:
From:

Your
Spouse

$

To:
From:

Your
Spouse

$

To:

You
YES

6. RESOURCES

(a) Do you own or are you buying any real estate other
than the home in which you live?

Go to (b)

Your Spouse
YES
NO

NO
Go to #7

Go to (b)

Go to #7

(b)Give the following information:
HOW IS IT USED? (If not used now, when was

DESCRIPTION OF PROPERTY (Include type and size of
structure, acreage or lot size, location.)

it last used and what is next planned use?)

Item 1

Item 1

Item 2

Item 2

ESTIMATED CURRENT
MARKET VALUE

OWNER'S NAME

TAX ASSESSED
VALUE

AMOUNT OF MORT- AMOUNT OWED
GAGE PAYMENT
ON ITEM

Item 1

$

$

$

$

Item 2

$

$

$

$

You
YES

7. (a) Do you own or does your name appear on the title

of any vehicles; e.g., cars, trucks, boats,
motorcycles, etc.?
(b)
OWNER'S NAME

DESCRIPTION
(YEAR, MAKE & MODEL)

Form SSA-8010-BK (05-2010) EF (05-2010)

Go to (b)
USED FOR

Go to #8

Go to (b)

EQUIPPED FOR
HANDICAPPED?
YES

Page 4

Your Spouse
YES
NO

NO

Go to #8

CURRENT
MARKET
VALUE

NO

AMOUNT
OWED

$

$

$

$

$

$

You
YES

8. (a) Do you own or are you buying any life insurance

policies?

Go to (b)

NO
Go to #9

Your Spouse
YES
NO
Go to (b)

Go to #9

(b)Give the following information on each policy:
OWNER'S NAME

NAME OF INSURED

NAME AND ADDRESS OF INSURANCE COMPANY

Policy (#1)
Policy (#2)
Policy (#3)
FACE
VALUE

POLICY NUMBER

CASH SURRENDER VALUE

LOANS AGAINST
YES
NO

DATE
PURCHASED

Policy (#1)

$

$

$

Policy (#2)

$

$

$

Policy (#3)

$

$

$

9. (a) Do you (either alone or jointly with any other

You

person) own any:

YES

Your Spouse
NO

YES

NO

Life estates or ownership interest in an unprobated estate?
Items acquired or held for their value as an investment?
Other equipment (business or non-business) or property
of any kind?

(b)Give the following information for any "Yes" answer in 9(a); otherwise go to #10.
OWNER'S NAME

NAME OF ITEM

VALUE

AMOUNT OWED
WHERE APPROPRIATE, GIVE NAME AND
ADDRESS OF BANK OR OTHER ORGANIZATION
ON ITEM

$

$

$

$

10. (a) Do you own or does your name appear (either alone or with
any other person's name) on any of the following items?

You
YES

Your Spouse
NO

YES

NO

Cash at home, with you, or anywhere else
Checking Accounts
Savings Accounts
Credit Union Accounts
Christmas Club Accounts
Certificates of Deposit
Notes
Stocks or Mutual Funds
Bonds
Other items that can be turned into cash
(b)Give the following information for any "Yes" answer in 10(a); otherwise go to #11.
OWNER'S NAME

NAME OF ITEM

Form SSA-8010-BK (05-2010) EF (05-2010)

VALUE

NAME AND ADDRESS OF BANK OR
AMOUNT OWED
OTHER ORGANIZATION IF APPROPRIATE
ON ITEM

$

$

$

$

$

$

$

$
Page 5

11. Do you give us permission to obtain any financial records from any
financial institution?

12. (a) Do you have any assets set aside for burial expenses
such as burial contracts, trusts, agreements, or anything
else you intend for your burial expenses? Include any
assets mentioned in items #6 through #10 above.
(b) DESCRIPTION (Where appropriate, give name
and address of organization and account/policy
number)

$

Item 2

$
FOR WHOSE BURIAL

NO

Your Spouse
YES
NO

You
YES

NO

Your Spouse
YES
NO

Go to (b)

VALUE

Item 1

You
YES

Go to #13

WHEN SET
ASIDE
(Month, Day, Year)

Go to (b)

Go to #13

OWNER'S NAME

WILL INTEREST EARNED OR APPRECIATION IN
VALUE REMAIN IN THE BURIAL FUND?

IS ITEM IRREVOCABLE?

Item 1

YES

NO

YES Go to #13

NO Explain in (c)

Item 2

YES

NO

YES Go to #13

NO Explain in (c)

(c) Explanation:
Item 1
Item 2
You
YES

13. (a) Do you own any cemetery lots, crypts, caskets,

vaults, urns, mausoleums or other repositories for
burial or any headstones or markers?

(b)

OWNER'S NAME

Go to (b)

Go to #14

FOR WHOSE
BURIAL

DESCRIPTION

NO

Your Spouse
YES
NO
Go to (b)

Go to #14

CURRENT
RELATIONSHIP
TO YOU OR MARKET VALUE
YOUR SPOUSE (if applicable)

$
$
You
YES

14. (a) Are you the sponsor of an alien admitted for

permanent residence in the United States?

Go to (b)

NO

Go to #18

Your Spouse
YES
NO
Go to (b)

Go to #18

(b)If you are filing this report on behalf of the alien claimant/recipient, go to #15. If you are filing this
report on behalf of your child (or your spouse's child) who is applying for/eligible for SSI, go to #17.
15.

You
YES

(a) Do you have any dependents?

Go to (b)

NO

Go to #16

Your Spouse
YES
NO
Go to (b)

Go to #16

(b)Give the following information about your dependent(s):
RELATIONSHIP TO
YOU OR SPOUSE

NAME

Form SSA-8010-BK (05-2010) EF (05-2010)

Page 6

FILING FOR/
RECEIVING SSI

You

16. A sponsor may be liable for any overpayments made

to an alien that result from the sponsor's failure to
provide correct information regarding deemable
income and resources. Do you agree to notify the
Social Security Administration immediately about any
changes in your income and resources and do you also
agree to report any change in your address?

Your

YES
Go to #18

NO
Explain in
Remarks
and go to
#18.

Spouse

YES
Go to #18

NO
Explain in
Remarks
and go to
#18.

17. Give the following information about the alien(s) you sponsor:
NAME OF
ALIEN

SPONSOR
YOU
SPOUSE

SOCIAL
SECURITY NUMBER

/

/

/

/

/

/

/

/

/

/

DATE OF
ADMISSION

FILING FOR/
RECEIVING SSI

REMARKS - (You may use this space for any explanations. Enter the item number before each explanation. If you need more space, use a signed form SSA-795).

Form SSA-8010-BK (05-2010) EF (05-2010)

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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.
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 the applicant/recipient is paid the correct amount.
We have asked you for permission to obtain, from any financial institution, any financial record about you that is held by the
institution. We will ask financial institutions for this information whenever we think it is needed to decide if the SSI applicant
or recipient is eligible or continues to be eligible for SSI benefits. Once authorized, our permission to contact financial
institutions remains in effect until one of the following occurs: (1) you notify us in writing that you are canceling your
permission, (2) we no longer consider your income and resources to be available to the SSI applicant or recipient, (3) the SSI
applicant is denied benefits in a final decision, or (4) the SSI recipient's eligibility for benefits terminates. If you do not give
or cancel your permission the SSI applicant or recipient may not be eligible for SSI and we may deny their claim or stop their
payments.

SIGNATURES
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.

18. Your Signature (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)
Telephone number(s) at which you may be contacted
during the day

SIGN
HERE

(

area code

)

Spouse's Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE
NOTE: If you are the representative payee and are filing this statement on behalf of another person (other
than your spouse), please print below your full name, followed by your title or relationship to the
person whose income and resources you are reporting (for example, "John J. Jones, Son").

Name (First, middle initial, last)

Title or Relationship

Your Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)

Zip Code

City and State

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

Your Residence Address (If different from your mailing address)
City and State

Zip Code

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

WITNESSES

Your statement does not normally 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 addresses.

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-8010-BK (05-2010) EF (05-2010)

Page 8

PRIVACY ACT STATEMENT
Sections 1614 and 1621 of the Social Security Act, as amended (42 U.S.C. 1382c(f) and 1383(3)), authorize us to collect this
information. The information is needed to enable the Social Security Administration to determine eligibility or continued
eligibility of an individual who is filing for or receiving monthly benefits. The information you furnish on this form is voluntary.
However, failure to provide all or part of this information could prevent an accurate and timely decision on this claim and could
result in the loss of some benefits.
We rarely use the information you supply for any purpose other than 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, audit, or investigative activities
necessary to assure the integrity 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.

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
revised
unless we display a valid Office of Management and BudgetPlease
control see
number.
We estimate that it will take about 12
minutes to read the instructions, gather the facts, and answer
the questions. SEND OR BRING THE COMPLETED
Paperwork
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office
is listedAct
under U. S. Government agencies in your
Reduction
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
Statment
below. MD 21235-6401. Send only
comments on our time estimate above to: SSA, 6401 Security
Blvd.,Baltimore,
comments relating to our time estimate to this address, not the completed form.
NAME OF SSI CLAIMANT/RECIPIENT

SOCIAL SECURITY NUMBER

/

DATE

/

REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income check is based on the information told to us. You must tell Social
Security every time there is a change - while we process this application AND if the person named above starts
receiving Supplemental Security Income. So that the individual continues getting the right payment amount, you
must report certain changes that happen to you.
Remember a change may make the SSI monthly payment bigger or smaller. Report changes in your income and the
income of your husband/wife or a child who lives with you. You must also report changes in things of value that
you and your spouse own.
You must tell us about any change within 10 days after the month it happens. If you do not report changes, we
may have to take as much as $25, $50, or $100 out of future checks the individual is due.

You can make your reports by telephone at the telephone number shown below
or you may report in person or by mail at the address shown below. See reverse
side of this page for "Changes to Report."

HOW TO
REPORT

Telephone Number (include area code) to call Social Security Office you may come in person or mail your request to:
if you have a question or something to report.

(

area code

)

-

Form SSA-8010-BK (05-2010) EF (05-2010)

Page 9

KEEP THIS PAGE FOR YOUR RECORDS

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

• You move.

• You are no longer a legal resident of the
United States.

• You (or your spouse) leave your household

for a calendar month or longer. For example,
you enter a hospital or visit a relative.

HOW YOU LIVE - You must report to Social Security if:
• Someone moves into or out of your household.
• Your
• The amount of money you pay toward
household expenses changes.
-

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.

• Births and deaths of any people with whom
you live.

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).

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

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

• The amount of help (money, food, 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.

YOU ARE UNMARRIED AND UNDER AGE 21 - A report to Social Security must be made if:

• You start or stop school.

• Your income changes.

• You get married.
YOU ARE SELECTED AS A REPRESENTATIVE PAYEE - You must report to Social Security if:

• The person for whom you are filing this statement 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 that person's representative payee.
Form SSA-8010-BK (05-2010) EF (05-2010)

Page 10

KEEP THIS PAGE FOR YOUR RECORDS

SSA will insert the following revised PRA Statement 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 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.