Form SSA-8150 Reporting Events - SSI

Form Approved
OMB No. 0960-0128

Social Security Administration

REPORTING EVENTS - SSI
USE THIS FORM ONLY WHEN THERE IS A CHANGE TO REPORT
PRINT NAME OF PERSON (OR COUPLE) THAT THIS REPORT IS ABOUT
NAME

SOCIAL SECURITY NUMBER

NAME

SOCIAL SECURITY NUMBER

HOW TO REPORT
There are 3 ways to report
1. Phone Social Security and explain the change.

2. Visit Social Security.

DOES THIS PERSON(S) ALSO RECIEVE SOCIAL SECURITY (CHECK ONE)
YES
NO
CHECKS?
NOTE: CHECK AND COMPLETE ONLY ITEMS THAT HAVE BEEN CHANGED SINCE YOU LAST REPORTED
TO SOCIAL SECURITY.
Check the blocks below to tell about changes for yourself or someone you live with.
DATE OF CHANGE
CHANGE OF ADDRESS (OR LIVING ARRANGEMENTS)

Tel No. _____________________of District Office.

3. Mail this form to Social Security.
Make sure you fill in:
Name of person(s) the report
is about
Social Security Number of
person(s)

Whether person(s) also
receives social security
(green) checks
What is being reported and
date of change
Your signature and address

Moved or changed address or will move soon.

Date:
Entered or left at an institution (such as a hospital, nursing home, jail or other facility
Print new address at bottom of form.)
Date:
Date:
The number of people living in the same household as you has changed
Date:
Leaving the United States for 30 days or more
CHANGE OF INCOME
Date:
Date:

Getting more or less other income (such as someone else paying your bills, support
payments, interest, dividends, gifts, inheritances, etc.)
Date:
CHANGE IN RESOURCES

NOTE: REMEMBER TO TELL US WHEN YOU MOVE EVEN IF YOUR MAILING ADDRESS FOR CHECKS HAS NOT CHANGED.

If you mail your report, please use this reporting form, address it to the nearest Social Security Office and place the form in the
mailbox. No postage necessary.

FAILURE TO REPORT
Your SSI payment may be reduced by up to $100 for each failure to report a change affecting your SSI payment. You are
also subject to a fine or imprisonment or both.

Have recently gotten a house, car, or other expensive item
No longer have a house, car, or other expensive item
Name has been added to another person's bank account, stocks, or bonds
CHANGES AFFECTING DISABLED OR BLIND RECIPIENTS

Date:
Date:
Date:

Privacy Act Statement
Sections 205(j) and 1631(a) of the Social Security Act allows us to collect the information requested on this
questionnaire. The information you provide will allow the Social Security Administration to monitor items that have
changed since you last reported to Social Security. The information you furnish on this form is voluntary.

Disabled or blind - condition improved
OTHER CHANGES

Date:

We may, however, disclose the information provided on this form in accordance with approved routine uses of the
Privacy Act (5 U.S.C. § 552a(b)), which include but are not limited to the following:

See Revised Privacy Act Statement Attached

Date:
Marriage, separation, divorce, annulment
Date:
Under age 22 - change in school attendance
Date:
Death
Fleeing prosecution, or to avoid custody, or confinement after conviction, a crime,
Date:
or an attempt to commit a crime, which is a felony
Date:
Violating a condition of your parole or probation under Federal or State law
REMEMBER TO REPORT CHANGES FOR BOTH YOURSELF AND ANYONE YOU LIVE WITH
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.
SIGN YOUR NAME
DATE SIGNED
NUMBER AND STREET APARTMENT NO. , P.O. BOX OR RURAL ROUTE (Print)
CITY AND STATE

ZIP CODE

COUNTY (if any)

TELEPHONE NUMBER (if any)

ALTHOUGH I LIVE AT THE ABOVE ADDRESS, I WANT CHECKS SENT TO:
NUMBER AND STREET PARTMENT NO. , P.O. BOX OR RURAL ROUTE
CITY AND STATE
Form SSA-8150-EV (10-2011) Destroy Prior Editions

ZIP CODE

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 make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level;
3. To comply with Federal laws requiring the disclosure of the information from our records; and,
4. To facilitate 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.
A complete list of routine uses for this information is available in Systems of Records Notice 60-0222. This notice,
additional information regarding this form, and information regarding our programs and systems, are 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 unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 10 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 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.

FOLD THIS GUMMED FLAP

Change in earnings from work (or a job recently started or ended)
Received increase or decrease in pension, veteran's check, unemployment,
railroad, or other payment

IMPORTANT TO REPORT
The law requires you to report changes in your circumstances which could affect your Supplemental Security Income
(SSI) payment. The kinds of changes you must report to Social Security are listed on the inside of this form (open flaps).
The booklet "What you have to know about SSI." tells more about reporting changes. If you do not have this booklet or if
you need help in making a report, get in touch with any Social Security Office. The people there will be glad to help you.

SOCIAL SECURITY ADMINISTRATION
BALTIMORE MD 21235
OFFICIAL BUSINESS
PENALTY FOR PRIVATE USE, $300

BUSINESS REPLY MAIL

FIRST-CLASS MAIL PERMIT NO. 18452 WASHINGTON,DC
POSTAGE WILL BE PAID BY SOCIAL SECURITY ADMINISTRATION

NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES

Open flaps of this form and read how to fill out this form.
After you have filled in the change(s) you want to report, seal the flap on form, AND MAIL
TO THE NEAREST SOCIAL SECURITY OFFICE.
NO POSTAGE IS NEEDED

Form SSA-8150-EV (10-2011)

Use the form ONLY when there is a change to Social Security.

Glue

Glue

SSA will insert the following revised Privacy Act Statement 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.
We will use the information you provide to monitor reporting events that may affect your
Supplemental Security Income (SSI) benefits eligibility.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to determine continued
eligibility of SSI benefits. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act Systems of Records Notice 60-0103, entitled, Supplemental Security
Income Record and Special Veterans Benefits. Additional information about this and other
system of records notices and our programs are available online at www.socialsecurity.gov or at
your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.