SSA-8203-BK Current Version

SOCIAL SECURITY ADMINISTRATION

Update

STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY
EI SSN
FOR SUPPLEMENTAL SECURITY INCOME PAYMENTS

Form Approved
OMB No. 0960-0416
For Official Use Only

Spouse's Name

Name and Address

Spouse's SSN
Check the Ones That Apply
C

NC

M

N

FS-APP

DO Code

FS-REF

Interviewer's Initials

Date Received

WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE
MARITAL STATUS/TRAVEL OUTSIDE THE UNITED STATES/LIVING ARRANGEMENTS
1.

Since the date above, has your marital status (or the marital status of your parents if you are a
child) changed?

Yes

No

2.

Since the date above, have you moved to a new address? If "yes," give the new address:

Yes

No

ADDRESS (Number, Street, City, State, and ZIP Code)
3.

Since the date above, have you been outside the United States (the 50 States, District of
Columbia, and Northern Mariana Islands)? If "yes," please give:
DATE(S) LEFT (month/day/year):

4.

DATE YOU MOVED
Yes

No

DATE(S) RETURNED (month/day/year)

Since the date above, have you spent a full calendar month in a hospital, nursing home, or other
Yes
institution? If "yes," please give:
DATE ENTERED (Month/day/year):
DATE LEFT (Month/day/year):
NAME OF INSTITUTION

No

ADDRESS (Number, Street, City, State and ZIP Code)
5.

Mark X in the box which best describes where you live:
House
Room
Nursing Home
Apartment
Mobile Home
Rest or Retirement Home

6.

Since the date above, has anyone moved into or out of the place where you live? (including births
and deaths) If "yes," please give:
NAME

7.

RELATIONSHIP

AGE

BLIND OR
DISABLED

YES

NO

Hospital
Rehabilitation Center

DATE MOVED DATE MOVED
IN
OUT

School
Other

RELATIONSHIP

Form SSA-8203-BK (04-2014) EF (04-2014)
Use (05-2010) EF (05-2010) edition until exhausted

AGE AND/OR DATE
OF BIRTH

Page 1

BLIND OR
DISABLED

YES

NO

No

INELIGIBLE CHILD
STUDENT

Do any other people live in the same household with you or your spouse? If "yes," please give the
following information about them (including children):
NAME

Yes
MARRIED

INCOME

Yes

No

INELIGIBLE CHILD
STUDENT

MARRIED

INCOME

8.
9.

LIVING ARRANGEMENTS (continued)
Do all of the people who live with you receive public assistance payments? (For example, welfare,
TANF, VA pension, general assistance, SSI.)

Yes

No

a. Do you, or your spouse living with you, own or are you buying the place where you live? If "yes,"
give: MONTHLY MORTGAGE PAYMENT AMOUNT:

Yes

No

b. Do you, or your spouse living with you, rent the place where you live?

Yes

No

c. If you are a child recipient living with your parents, do your parents own or rent the place where you
live?

Yes

No

d. Does someone else who lives with you own or rent the place where you live?

Yes

No

e. If the place where you live is rented give,
LANDLORD'S NAME
ADDRESS
(Number, Street, City, State and ZIP Code)

MONTHLY
RENT

LANDLORD'S PHONE

f. If the place where you live is rented, are you (or anyone living with you) the parent or child of your
landlord or your landlord's spouse?
If "yes," give the name of the household
member who is the related person
g. If a. or b. is answered "yes," does any one who lives with you (other than your spouse) pay for or
give you money for food, mortgage or rent, property insurance or taxes, heating fuel, gas, electricity,
water, sewerage, or garbage collection services?

Yes

No

Yes

No

Yes

No

b. Help you pay the mortgage, rent, property insurance, property taxes, and/or sewerage charges?

Yes

No

c. Give you or help you pay for food, gas, electricity, heating fuel, water, and/or garbage collection
service?

Yes

No

10. Since the date on page 1, did anyone not living with you: a. Give you a free place to live?

If "yes," to a., b., or c., complete the following:
SOURCE
TYPE OF HELP

NAME/ADDRESS (Number, Street, City, State, ZIP Code)

PHONE NUMBER

11. Since the date on page 1, did anyone give you gifts which are not cash?
If "yes," complete the following:
SOURCE
DESCRIPTION OF
PHONE NUMBER
ARTICLE
NAME/ADDRESS (Number, Street, City, State, ZIP Code)

MONTHLY
AMOUNT

MONTHS
RECEIVED

Yes
MONTHS
RECEIVED

No

VALUE

EARNED INCOME
12. Since the date on page 1, have you, or your spouse living with you, worked OR do you expect to
work in the next 14 months? If "yes," please give:

Yes

a. Amounts for Past Months
NAME OF
WORKER

EMPLOYER'S NAME, ADDRESS
(Number, Street, City, State, ZIP Code)
AND PHONE NUMBER

GROSS WAGES
Often
Amount How
Paid

DATES OF
EMPLOYMENT
From:
To:
From:
To:

Form SSA-8203-BK (04-2014) EF (04-2014)

Page 2

No

EARNED INCOME (continued)
b.
Estimates
for
Current
and
Future
Months
12.
Month
Amount

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Month
Amount

13. Since the date on page 1, have you, or your spouse living with you, been self-employed or expect to
be self-employed in the current taxable year? If "yes," please give:
NAME OF
SELF-EMPLOYED
PERSON

TYPE OF BUSINESS

LAST YEAR'S
GROSS
INCOME

THIS YEAR'S ESTIMATED

NET INCOME
(OR LOSS)

GROSS
INCOME

NET INCOME
(OR LOSS)

Yes

No

DATES OF SELFEMPLOYMENT
From:
To:
From:
To:

you are disabled, do you have any special expenses that you paid that are related to your illness or
14. If
Yes
No
injury and which are necessary for you to work?
UNEARNED INCOME
15. Since the date on page 1, have you, or your spouse living with you, received, or do you expect to receive in the next
14 months, any of the income listed below:
a. Private pensions, annuities (other than Social Security, SSI, or food stamps)?

Yes

No

b. Unemployment or worker's compensation?

Yes

No

c. TANF or State or local assistance based on need?

Yes

No

d. Veterans Administration benefits (based on need, not based on need, education)?

Yes

No

e. Rental/lease income?

Yes

No

f. Alimony or child support?

Yes

No

g. Dividends or royalties?

Yes

No

h. Interest earned on money in bank accounts (including interest on checking accounts)?

Yes

No

i. Money from a trust fund?

Yes

No

j. Money from any other person or organization?

Yes

No

If the answer is "yes," to any of these types of unearned income, please give:
TYPE OF
RECEIVED
FREQUENCY DATES
RECEIVED BY
AMOUNT
OR EXPECTED
INCOME
From:

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

To:
From:
To:
RESOURCES: THINGS YOU OWN
16. Do you, or your spouse living with you, own any of the following items (answer "yes" if your name appears alone or
with any other person as the owner or part owner of any of these items):
a. Cash (with you, at home, in a safe deposit box)?

Yes

No

b. Checking accounts?

Yes

No

c. Savings accounts?

Yes

No

d. Credit union accounts?

Yes

No

Form SSA-8203-BK (04-2014) EF (04-2014)

Page 3

RESOURCES: THINGS YOU OWN (continued)
16. e. Christmas club accounts?
Cont.
f. Savings certificates/certificates of deposit?

Yes

No

Yes

No

g. Promissory notes or IOU's?

Yes

No

h. Stocks or bonds?

Yes

No

i. Other items that can be cashed or sold?

Yes

No

If "yes," please give the following information:
NAME OF EACH ITEM

TOTAL VALUE OF
EACH ITEM

OWNER(S) OF EACH ITEM

NAME AND ADDRESS OF BANK,
COMPANY, OR ORGANIZATION

17.

Do you give us permission to obtain any of your financial records from any financial institution?

Yes

No

18.

Do you, or your spouse living with you, own or are you buying any life insurance policies?
If " yes ," please give the following information:

Yes

No

NAME OF OWNER

POLICY NUMBER

19.

NAME OF INSURED

TOTAL FACE VALUE
OF POLICY

CASH SURRENDER
VALUE

NAME AND ADDRESS OF INSURANCE COMPANY

WHEN WAS THE
POLICY PURCHASED

IF THERE IS A LOAN AGAINST
THE POLICY, GIVE THE AMOUNT

Is your name, or the name of your spouse living with you, on the title of any vehicles (for example,
car, truck, boat, camper, motorcycle, etc.)? If "yes," please give the following information:
NAME OF OWNER(S)

YEAR OF
VEHICLE(S)

MAKE AND MODEL

CURRENT MARKET
VALUE

Yes

No

HOW MUCH IS OWED
ON VEHICLE(S)

MAIN PURPOSE FOR WHICH THE VEHICLE(S) IS USED (For example, employment, to obtain medical treatment,
etc.)

20.

Do you, or your spouse living with you, own or are you buying any real estate (land or buildings or
other structures on the land)? (Include property outside the U.S., inherited property, life estates. Do
not include your home.) If "yes," please give the following information:
NAME OF OWNER

ESTIMATED CURRENT
MARKET VALUE

TAX ASSESSED
VALUE IF KNOWN

DESCRIPTION (Include type and size of structures,
acreage or lot size, and location of property)

Form SSA-8203-BK (04-2014) EF (04-2014)

AMOUNT OF MORTGAGE PAYMENT (If any)

Yes

AMOUNT OWED ON
THE PROPERTY

USE (Describe how the property is used. If not in use,
give date of last use and next planned use.)

Page 4

No

RESOURCES (continued)
21. Do you, or your spouse living with you, own any of the following items (answer "yes" if your name or
your spouse's name appears alone or with any other person as the owner or part owner of any of
these items). a. Other household or personal items not already mentioned worth more than $500?
b. Other equipment (business or nonbusiness) or property of any kind (not already included on this
form)?
If "yes," please give the following information:
OWNER(S) OF EACH ITEM

NAME OF EACH ITEM

DESCRIPTION (Where appropriate, give name and
address of bank, company, or organization)

TOTAL VALUE OF EACH
ITEM

RELATIONSHIP TO YOU
OR YOUR SPOUSE

YES

23.

NO

VALUE

WHEN DID YOU
SET IT ASIDE
(Month/Day/Year)

NAME OF OWNER

a. Since the date on page 1, have you, or your spouse living with you, sold,
transferred title, disposed of or given away any money, or other property,
including money or property in foreign countries?
b. If you co-owned property with another person(s), did you or any co-owner sell,
transfer, or give way any co-owned money or property?

Page 5

Yes

No

Yes

No

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

YES

NO

FOR WHOSE BURIAL

You

Yes

No

Your Spouse

Yes

No

You

Yes

No

Your Spouse

Yes

No

IF "YES" TO (A) OR (B), GO TO (C). IF NO TO BOTH, GO TO 24.
Form SSA-8203-BK (04-2014) EF (04-2014)

No

DESCRIPTION AND VALUE

b. Do you, or your spouse living with you, have any money or other assets, such as, burial contracts,
trusts, insurance policies, agreements, or anything else you intend to use for your burial expenses?
(Include assets listed in items 16-21 if appropriate.) If "yes," please give:

IS IT IRREVOCABLE

Yes

USE (Describe how the property is used. If not in use,
give date of last use and next planned use.)

FOR WHOSE BURIAL

DESCRIBE WHAT YOU
HAVE SET ASIDE

No

HOW MUCH IS OWED ON
EACH ITEM

22. a. Do you, or your spouse living with you, own any headstones or markers, cemetery lots, crypts,
urns, mausoleums, or other repositories for burial? If "yes," please give:
NAME OF OWNER

Yes

RESOURCES (continued)
23.
Cont.

SOLD ON
OPEN MARKET

GIVEN AWAY

TRADED FOR
GOODS/SERVICES

DESCRIPTION OF PROPERTY

VALUE OF PROPERTY AND/OR
AMOUNT OF CASH GIFT

OWNER'S/CO-OWNER'S NAME(S)

NAME AND ADDRESS OF PURCHASER OR RECIPIENT

SALE PRICE OR OTHER
CONSIDERATION RECEIVED

DO YOU STILL OWN PART OF THE PROPERTY? IF YES, EXPLAIN

DATE OF DISPOSAL

RELATIONSHIP TO OWNER

ARE ADDITIONAL CONSIDERATION OR
PROCEEDS EXPECTED? EXPLAIN

Yes

No

24. Since the date on page 1, have you (or your spouse living with you) had any change in health
insurance coverage or other insurance that pays for medical bills? (Do not include Medicare, but do
include insurance such as accident, automobile, or casualty if it covers medical bills for any reason.)

Yes

No

IF YOU LIVE IN CALIFORNIA, PLEASE DO NOT ANSWER QUESTION 25 BELOW.
25.

You

Your Spouse

a. Are you currently receiving food stamps?
If YES, go to "b." If NO, go to ''c.''

Yes

No

Yes

No

b. Have you received a recertification notice within the past 30 days?
If YES, go to "e." If NO, go to question 26.

Yes

No

Yes

No

c. Have you filed for food stamps in the last 60 days?
If YES, go to "d." If NO, go to ''e.''

Yes

No

Yes

No

d. Have you received a favorable decision?
If YES, go to question 26. If NO, go to "e."

Yes

No

Yes

No

e. Is everyone in the household applying for or receiving SSI?
If YES, go to "f." If NO, go to question 26.

Yes

No

Yes

No

f. May I take your food stamp application today?
If YES, go to question 26. If NO, explain in "g."

Yes

No

Yes

No

g. Explanation

Form SSA-8203-BK (04-2014) EF (04-2014)

Page 6

26. a. Which language do you prefer to use when speaking to us?
b. Which language do you prefer us to use when writing to you?
27. Please answer the following questions:
a. Are you age 62 or older?

Yes

No

b. If you are age 50 or older, are you a widow(er)?

Yes

No

c. If you are age 50 or older and divorced, is your divorced spouse deceased?

Yes

No

d. If you were disabled before age 22, do you have a parent who is age 62 or older, disabled, or
Yes
No
deceased?
28.
You
Your Spouse, if filing
(a) Do you have any unsatisfied felony warrants for
Yes
Yes
No
No
your arrest?
Go to (b)
Go to (b)
(b) In which state or country was this warrant issued?

No

month, day, year

(d) Date warrant satisfied:

You
Yes
Go to (b)

29. (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

Name of State/Country

No

month, day, year

(d) Date warrant satisfied:
REMARKS

Page 7

Go to (c)
Yes
Go to (d)

No

month, day, year
Your Spouse, if filing
Yes
No
Go to (b)
Name of State/Country

Go to (c)
Yes
Go to (d)

(c) Was the warrant satisfied?

Name of State/Country

Go to (c)
Yes
Go to (d)

(c) Was the warrant satisfied?

Form SSA-8203-BK (04-2014) EF (04-2014)

Name of State/Country

Go to (c)
Yes
Go to (d)

No

month, day, year

REMARKS Continued

If the address where you live is different than the address where you get your mail, please give the address where
you live:
Address (Number and Street)
City/State
ZIP Code
YOUR AUTHORIZATION
I give my permission for the Social Security Administration to check the information I have given on this form, and to ask my
employer(s) for information about my wages. I understand that the Social Security Administration will compare its records
with records from other State and Federal agencies to make sure I am paid the correct amount of benefits. 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.
SIGNATURES (Write in ink)
Your Signature (First name, middle initial, last name)

Date

Spouse's Signature (First name, middle initial, last name)
(Sign Only if Receiving SSI Payments)

Date

Area Code and Telephone Number Where
You Can Be Reached

WITNESSES (Write in ink)
If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign below and give their
full names and addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number, Street, City, State, ZIP Code)

Address (Number, Street, City, State, ZIP Code)

REPRESENTATIVE PAYEE (Write in ink)
Your Title or Relationship to the Recipient Area Code and Telephone
Number Where You Can Be
Reached

Date

Your full name (First name, middle initial, last name)
Please print here
Please sign here
Form SSA-8203-BK (04-2014) EF (04-2014)

Address (Number, Street, City, State, ZIP Code)

Page 8

RIGHTS AND RESPONSIBILITIES
NAME

SOCIAL SECURITY NUMBER

DATE

NAME

SOCIAL SECURITY NUMBER

DATE

Telephone Number (include area code) to Social Security Office you may visit in person or send in your request:
call if you have a question or something to
report.
Privacy Act Statement
Collection and Use of Personal Information
Section 1611(c) of the Social Security Act, as amended, authorizes us to collect this information. We will use the information
you provide to determine your continuing eligibility for supplemental security income payments.
Furnishing us this information is voluntary. However, failing to provide all or part of the information could prevent us from
making a timely decision on your request.
We rarely use the information you supply for any purpose other than for determining continued eligibility. However, 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 and improvement of
Social Security programs (e.g., to the Bureau of Census and to private entities under contract with us).
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
incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act Systems of Records Notices
entitled, Claims Folder System, 60-0089. Additional information about this and other systems of records notices and our
programs are available from our Internet website 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 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. To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only
comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Reporting Responsibilities
• The amount of your SSI check is based on the information you tell us. To continue getting the right payment amount, you
must report certain changes that happen to you. Changes could make your check bigger or smaller.
• You must tell us about changes within 10 days after the month they happen. If you do not report changes, we may have to
take as much as $25, $50, or $100 out of future checks you receive.
• You must also report changes in income for your ineligible spouse or children who live with you, or your sponsor or
sponsor's spouse if you are an alien. You must also report if any of these people buy or sell anything of value.
• A List of Most of the Changes You Must Report Is On The Next Page.
How To Report Changes
You can report changes in any of the following ways:
• Call us, toll free, at 1-800-772-1213.
• Call your local Social Security Office at the number at the top of this form.
• By mail or in person - see the address at the top of this form.
Important Facts About Food Stamps
• You can apply for food stamps at the Social Security Office if you and everyone in your household get or apply for SSI.
• The Social Security Office will help you fill out the food stamp application. You do not have to go to the food stamp office
to apply.
Form SSA-8203-BK (04-2014) EF (04-2014)

Page 9

CHANGES TO REPORT
WHERE YOU LIVE—You must report to Social Security if:
• You move.

• You leave the United States for 30 days or more.

• You (or your spouse) leave your household for
a calendar month or longer. For example, you
enter a hospital or visit a relative.

• You are released from a hospital, nursing home, etc.
• You are no longer a legal resident of the
United States.

HOW YOU LIVE—You must report to Social Security:
• If someone moves into or out of your household.
• If the amount of money you pay toward
household expenses changes.
• If your former spouse dies.
• Births and deaths of any people with whom you
live.

• Changes in your marital status:
• 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.
• Your spouse dies.

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.
• You become eligible for benefits other than SSI.

HELP YOU GET FROM OTHERS—You must report to Social Security if:
• The amount of help (money, food or payment of
• Someone stops helping you.
household expenses) you receive goes up or
• Someone starts helping you.
down.
THINGS OF VALUE THAT YOU OWN—You must report to Social Security if:
• The value of your resources goes over $2,000
• You sell or give any things of value away.
when you add them all together ($3,000 if you are
• You buy or are given anything of value.
married and live with your spouse).
YOU ARE BLIND OR DISABLED—You must report to Social Security if:
• Your condition improves or your doctor says you
can return to work.
• You go to work.
YOU ARE UNMARRIED AND UNDER AGE 22—A report to Social Security must be made if:
• You are under age 18 and live with your parent
• There are changes in the income, school
(s), ask your parents to report if they have a
attendance (if between the ages of 18 and
change in income, a change in their marriage, a
21), or marital status of ineligible children
change in the value of anything they own, or
who live in your household.
either has a change in residence.
• You get married.

• You start or stop school.

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES—You must report any
changes to Social Security.
YOU ARE A REPRESENTATIVE PAYEE—You must report to Social Security if:
• The person for whom you receive SSI checks 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 the person's representative payee.
Form SSA-8203-BK (04-2014) EF (04-2014)

Page 10