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
Parent

Check Which: (Spouse of)
Sponsor

Essential Person

1. PUBLIC INCOME MAINTENANCE PAYMENTS
(Governmental Assistance Based on Need)

Parent
Your Spouse

You

(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?

YES

NO

YES

NO

Go to (b) Go to #3 Go to (b) Go to #3

(b) Give the following information about the payments:
TYPE

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

IDENTIFICATION
NUMBER

SOURCE

$
You
Social Security
Monthly
Your
Administration
$
Spouse
State or Local Gov$
>
You
ernment Assistance
Your
$
>
Based on Need
Spouse
Refugee Assistance
$
>
You
Payments Based on
Your
$
>
Need
Spouse
$
>
You
Aid to Families with
Your
Dependent Children
$
>
Spouse
$
>
General Assistance
You
Bureau of Indian
from the Bureau of
Your
Affairs
$
>
Indian Affairs
Spouse
$
You
Disaster Relief
Your
$
Spouse
$
You
Dept. of Veterans
Veterans Benefits
Your
Based on Need
Affairs
$
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.
Supplemental
Security Income

2. OTHER INCOME YOU RECEIVED WHILE RECEIVING PUBLIC INCOME
MAINTENANCE PAYMENTS
(a) Have you received any other income in addition to any public income
maintenance payments shown in #1?
Form SSA-8010-BK (05-2015) UF (05-2015)
Destroy Prior Editions

Page 1

You
YES

Your Spouse
NO

YES

NO

Go to (b) Go to #6 Go to (b) Go to #6

2. (b)

If you are:

(Cont)

Then:

• The sponsor of an alien
• The spouse of a sponsor
• An essential person

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.

You
(a) Have you received wages since the first moment of the filing
date month or since the last determination?

YES

Your Spouse
YES

NO

Go to (b)
Go to (d)
(b) Name and Address of Employer (include telephone number and area code, if known)

Go to (b)

NO
Go to (d)

Your Spouse

You

(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)

Your Spouse
YES
NO

NO
Go to #4

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)
Your Spouse

You

(f) Give the following information:
RATE OF PAY
$

per

Your
Spouse $

per

You

AMOUNT WORKED PER
PAY PERIOD

HOW OFTEN
PAID

PAY DAY OR
DATE PAID

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

YES
Go to (h)

(h) Explain change:
You

Form SSA-8010-BK (05-2015) UF (05-2015)

Your Spouse

Page 2

DATE LAST PAID
(Month, day,year)

Your Spouse
NO
Go to #4

YES
Go to (h)

NO
Go to #4

4. (a) Have you been self-employed at any time since the beginning
of the taxable year in which the filing date month or the last
determination occurs or do you expect to be self-employed in
the current taxable year?

You
YES

Your Spouse
NO

Go to (b)

YES

Go to #5

Go to (b)

NO
Go to #5

(b) Give the following information:
LAST YEAR'S:
NET
GROSS
INCOME INCOME
LOSS

TYPE OF BUSINESS

THIS YEAR'S:
NET
GROSS
INCOME INCOME
LOSS

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

DATES OF
SELFEMPLOYMENT

You

Your
Spouse

5. (a) Since the first moment of the filing date month or the last
determination, 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 (05-2015) UF (05-2015)

Page 3

You
YES

Your Spouse
NO

YES

NO

5. (b) Give the following information for any "Yes" answer in 5(a); otherwise go to #6.
Source (Name/Address of
(Cont) Person
Type of
Dates Expected
Amount Frequency
Person, Bank, Company, or
Receiving Income
or Received
Organization)

IDENTIFYING
NUMBER

From:
You

$
To:
From:

You

$
To:
From:

You

$
To:
From:

Your
Spouse

$

Your
Spouse

$

Your
Spouse

$

To:
From:
To:
From:
To:

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

You
YES
Go to (b)

Your Spouse
NO
Go to #7

YES
Go to (b)

NO
Go to #7

(b) Give the following information:
DESCRIPTION OF PROPERTY (Include type and size of
structure, acreage or lot size, location.)
Item 1

HOW IS IT USED? (If not used now, when was it
last used and what is next planned use?)
Item 1

Item 2

Item 2

ESTIMATED
TAX ASSESSED
CURRENT MARKET
VALUE
VALUE

OWNER'S NAME

AMOUNT OF
MORTGAGE
PAYMENT

AMOUNT
OWED ON
ITEM

Item 1

$

$

$

$

Item 2

$

$

$

$

7. (a) Do you own or does your name appear on the title of any
vehicles; e.g., cars, trucks, boats, motorcycles, etc.?

You
YES
Go to (b)

(b)
OWNER'S
NAME

DESCRIPTION (YEAR,
MAKE & MODEL)

Form SSA-8010-BK (05-2015) UF (05-2015)

USED
FOR

Page 4

Your Spouse
NO
Go to #8

YES
Go to (b)

NO
Go to #8

EQUIPPED FOR CURRENT
HANDICAPPED? MARKET
VALUE
YES
NO

AMOUNT
OWED

$

$

$

$

$

$

8.

You
YES

(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

9.

LOANS AGAINST
YES
NO

CASH SURRDATE
ENDER VALUE PURCHASED

Policy (#1)

$

$

$

Policy (#2)

$

$

$

Policy (#3)

$

$

$
You

(a) Do you (either alone or jointly with any other person) own any:

YES

NO

Your Spouse
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

$

$

$

$

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?
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
Form SSA-8010-BK (05-2015) UF (05-2015)

AMOUNT
OWED ON
ITEM

VALUE

Page 5

WHERE APPROPRIATE, GIVE
NAME AND ADDRESS OF BANK
OR OTHER ORGANIZATION

You
YES

Your Spouse
NO

YES

NO

10. (b) Give the following information for any "Yes" answer in 10(a); otherwise go to #11.
(Cont)
OWNER'S NAME

NAME OF ITEM

VALUE

NAME AND ADDRESS OF BANK
OR OTHER ORGANIZATION IF
APPROPRIATE

$

$

$

$

$

$

$

$

11.

You
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)

VALUE

Item 1

$

Item 2

$

FOR WHOSE BURIAL

AMOUNT
OWED ON
ITEM

IS ITEM
IRREVOCABLE?

YES

Your Spouse
NO

You
YES

YES

NO

Your Spouse
NO

WHEN SET
ASIDE
(Month, Day, Year)

YES

NO

OWNER'S NAME

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

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
Form SSA-8010-BK (05-2015) UF (05-2015)

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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

DESCRIPTION

You

Your Spouse

YES

NO

YES

NO

Go to (b) Go to #14
Go to (b) Go to #14
RELATIONSHIP
CURRENT
FOR WHOSE
TO YOU OR MARKET VALUE
BURIAL
YOUR SPOUSE (if applicable)
$
$

14.

You
(a) Are you the sponsor of an alien admitted for permanent
residence in the United States?

Your Spouse

YES
Go to (b)

NO
Go to #18

YES
Go to (b)

NO
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
(a) Do you have any dependents?

YES
Go to (b)

Your Spouse
NO
Go to #16

YES
Go to (b)

NO
Go to #16

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

NAME

16.

FILING FOR/RECEIVING SSI

You
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?

YES
Go to #18

Your Spouse
NO
Explain in
Remarks
and go to
#18.

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

SOCIAL SECURITY
NUMBER

Form SSA-8010-BK (05-2015) UF (05-2015)

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SPONSOR
YOU

DATE OF
FILING FOR/
ADMISSION
RECEIVING
SSI
SPOUSE

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 (05-2015) UF (05-2015)

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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 statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be subject to a fine or imprisonment.
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
(
)
area code

Spouse's Signature (First name, middle initial, last name) (Write in ink)

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").
Title or Relationship

Name (First, middle initial, last)

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

City and State

ZIP Code

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

ZIP Code

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

Your Residence Address (If different from your mailing address)

City and State

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)

Form SSA-8010-BK (05-2015) UF (05-2015)

Address (Number and street, city, state, and ZIP code)

Page 9

PRIVACY ACT STATEMENT

See Revised Privacy Act
Statement Attached

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. We will use the information you provide to determine eligibility or continued eligibility of an individual who is
filing for or receiving benefits.
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 for
the reasons explained above. 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);
2. To facilitate statistical research, audit, or investigative activities necessary to assure 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
System of Record Notice entitled, Supplemental Security Income Record and Special Veterans Benefits, (60-0103).
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.
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. 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.
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.

• HOW TO
REPORT

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."

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
KEEP THIS PAGE FOR YOUR RECORDS
Form SSA-8010-BK (05-2015) UF (05-2015)
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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.
• The amount of money you pay toward
household expenses changes.
• 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).

✔

• Your 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.

• 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 (05-2015) UF (05-2015)

Page 11

KEEP THIS PAGE FOR YOUR RECORDS