Form SSA-8001-BK Application For Supplemental Security Income

5. If filing as spouse or couple

6(a) Sex

7(a)

8(a) Social Security Number

If filing for child
(b) Parent 1 ’s Name(s)

6(b)Sex

7(b)

8(b) Social Security Number

If filing for child
(c) Parent 2 ’s Name(s)

6 (c) Sex

7(c)

8(c) Social Security Number

(a) Spouse’s Name(s)

9.

Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d)

(a) Your Other Name(s) (including Name at Birth)

Social Security Number

(b) Spouse’s Other Name(s) (including Name at Birth)

Social Security Number

(c) Parent 1’s Other Name(s) (including Name at Birth)

Social Security Number

(d) Parent 2’s Other Name(s) (including Name at Birth)

Social Security Number

21. (a) Do you have any felony arrest warrants for escape from custody,
flight to avoid prosecution or confinement, or flight escape?

22. (a) Have you violated a condition of your probation or
parole under Federal or State laws?
(b) In which State did your violation occur?

Name of State

Name of State
Go to (c)

(c ) Date of violation:

Go to (c)

(month, day, year)

(month, day, year)

(a) Trust(s)

$

$

(b) Vehicles (auto, truck,
camper, boat, motorcycle)
How many?

$

$

$

$

$

$

$

$

(c) Property other than
the home you live in (land,
houses, buildings,
property in foreign
countries)
(e) Savings, checking
accounts, stocks, bonds?
(f) Items held for potential
value or investment (for
example, coin or card
collection, jewelry in
safe deposit box)

(g) Insurance policies
(h) Other items that can
be turned into cash

$

$

$

$