SSA-8001-BK (current)

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

TEL

SOCIAL SECURITY ADMINISTRATION

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 (11-2009) 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)
(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? (month, day year)

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

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?

NO
Go to #13

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

American Indian born in Canada

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 (11-2009)

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

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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):

Go to #16

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

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 (11-2009)

)

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)

You

NO
Go to #20

Name of State/Country

(month, day, year)
Date
Left:

(month, day, year)

Date
Returned:
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)

(month, day, year)

(d) Date warrant satisfied:
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?

YES
Go to (b)

You

Go to (c)
YES
Go to (d)

(month, day, year)

Name of State/Country

Go to (c)
YES
Go to (d)

NO
Go to #21

(month, day, year)

(d) Date warrant satisfied:
Page 4

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?

Form SSA-8001-BK (11-2009)

NO
Go to #20

NO
Go to #19

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 (11-2009)

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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

DO YOU STILL OWN PART OF
THE PROPERTY?

Item #1

YES

NO

Item #2

YES

NO

Item #3

YES

NO

SOLD ON OPEN MARKET?

GIVEN AWAY?

TRADED FOR
GOODS/SERVICES?

Item #1

YES

NO

YES

NO

YES

NO

Item #2

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

Item #3

Form SSA-8001-BK (11-2009)

Page 6

You

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

YES

Your Spouse, if filing
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.)
27. 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

Source of
Income

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

YES
Go to (b)

NO
Go to #29

(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 #30

YES
Go to (e)

NO
Go to #30

(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 #30

NO
Go to (e)

YES
Go to #30

NO
Go to (e)

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

YES
Go to #30

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

NO
YES
Explain in (f) Go to #30

NO
Explain in (f)

(f) Explanation:

PART VI- MISCELLANEOUS
ANSWER #30 ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISE
G0 T0 #31.
Your Social Security Number
30. Name of Person Requesting Benefits Relationship to Claimant

Form SSA-8001-BK (11-2009)

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

Form SSA-8001-BK (11-2009)

Page 8

PART VIII -- IMPORTANT INFORMATION -- PLEASE READ CAREFULLY
31. 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. 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 you are eligible or if you
continue 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 or your spouse notify us in writing that you are cancelling your permission, (2)
your application for SSI is denied in a final decision, (3) your eligibility for SSI terminates, or (4) we no longer consider your
spouse's income and resources to be available to you. If you or your spouse do not give or cancel your permission you
may not be eligible for SSI and we may deny your claim or stop your payments.

PART IX - SIGNATURES
32.

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.

33. Your Signature (First name, middle initial, last name) (Write in ink.) Date (Month, day, year)
Telephone Number(s) where we can contact you
during the day:

SIGN
HERE

(

)

-

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

SIGN
HERE
35. 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

36. 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

37. If you are blind or visually impaired, check the type of mail you want to receive from us:
Certified

Regular

Regular with a follow-up phone call

WITNESSES
38. 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 (11-2009)

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.
some SSI payments if you do not let us know right away.

You could lose

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 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.
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 19-20 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.

Form SSA-8001-BK (11-2009)

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