Form SSA-8000-BK Application for Supplemental Security Income (SSI)

Form SSA-8000-BK (03-2017) UF
Discontinue Prior Editions
Social Security Administration

0TEL

Page 1 of 24
OMB No. 0960-0229
Do Not Write in This Space
DATE STAMP

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Note: Social Security Administration staff or others who help people apply for
SSI will fill out this form for you.

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.

TYPE OF CLAIM

O Individual

D

Individual with
Ineligible Spouse

Filing Date (month, day, year)
O Receipt

O Protective

O SNAP FS-SSA/APP I O SNAPFS-Referred

Preferred Language
Spoken:
Written:

D Couple

D

O Child with
Parent(s)

Child

PART 1 - BASIC ELIGIBILITY - Answer the questions below beginning with the first moment of
the filing date month.
Social Security Number
Sex
Birthdate
1. (a) First Name, Middle Initial, Last Name
(month, day, year)
OMale
(b) Did you ever use any other name(s) (including maiden
name) or any other Social Security Number(s)?

(c) Other Name(s)

D Female

D NO Go to (d)

DYES Go to (c)

Other Social Security Number(s) used

(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:

2.

Parent 1's Name(s)
Parent 1's Other
Name(s)(Including
Name
at Birth)
(Number & Street, Apt.
Address
Applicant's Mailing

3.

ZIP Code
City and State(U.S.)
Postal Code I
State/Province/Region (Foreign)
Claimant's Residence Address (If different from applicant's mailing address)

Mother's
Maiden Name:

4.

City and State(U.S.)
State/Province/Region (Foreign)

Father's
Name:

No., P.O. Box,

I

Parent 2's Name(s)
Parent 2's Other
Names(s) (Including
Route) at Birth)
Rural Name

ZIP Code
Postal Code

Go to #2

County
Country

County
Country

DIRECT DEPOSIT PAYMENT INFORMATION ADDRESS (FINANCIAL INSTITUTION)

Routing Transit Number

Account Number

O Checking
O Savings

O Enroll in Direct Express
D Direct Deposit Refused

Form SSA-8000-BK (03-2017) UF
5.
(a) Are you married?
(b) Date of marriage:

Page 2 of 24
DYES Go to (b)

D NO Go to #6

(month, day, year)

(c) Spouse's Name (First, middle initial, last)

Birthdate
Social Security Number
(month, day, year)

d) Did your spouse ever use any other name(s) (including
maiden name) or Social Security Number(s)?
(e) Other Name(s)

DYES Go to (e) D NO Go to (f) Other

(f) Are you and your spouse living together?

D YES Go to #6

(g) Date you began living apart

Other Social Security Number(s) Used

D NO Go to (g)

(month, day, year)

(h) Address of spouse or name of someone who knows where spouse is. (Complete only if spouse is age 65, blind
or disabled.)

6.

Your Spouse, if filing
You
YES
DYES
ONO
ONO
D
Go to #76c
Go to #7 6c
Go to (b)
Go to (b)
(b) Give the following information about your prior marriages your former spouse. If there was more than one prior former
e
remaining
th
information in Remarks and go to #4. #7.
marriage, show
(a) Have you had any other marriages?
If never married, check this box D

YOU

YOUR SPOUSE

FORMER SPOUSE'S NAME
(including maiden name)
BIRTHDATE (month, day,
year)
SOCIAL SECURITY
NUMBER
DATE OF MARRIAGE
(month, day, year)
DATE MARRIAGE ENDED
(month, day, year)
HOW MARRIAGE ENDED
7. If you are filing for yourself, go to (a); if you are filing for a child, go to (e)(d).
(a) Are you unable to work because of illnesses,
injuries or conditions?
(b) Enter the date you became unable to work.

You

O YES
ONO
Go to(b)
Go to #8
(month, day, year)

Your Spouse
D YES
ONO
Go to #7#8
Go to(b)
(month, day, year)

Page 3 of 24

Form SSA-8000-BK (03-2017) UF
7. (c) What are your illnesses, injuries or conditions?
You

Go to (d)
Your Spouse
Go to (d)
( d) If you were unable to work because of illnesses, injuries, or conditions before you were age 22, do you have a
parent who is age 62 or older, unable to work because of illnesses, injuries or conditions, or deceased?
DYES

Parent's Name:
Social Security Number:
Address:

D NO

Go to #8

(e) When did the child become disabled?

(month, day, year)
Go to ( f)

(f) What are the child's disabling illnesses, injuries or
conditions?

Go to (g)
(g) Does the child have a parent(s) who is age 62 or older, unable to work because of illness, injuries, or conditions,
or deceased?
DYES

Parent's Name:
Social Security Number:
Address:

D NO
8.

Birthplace

Go to #8
City

Country (if other than the U.S.)

State

You
Your Spouse,
if filing
9.

10.

ONO
Go to #10

Go to #9
Your Spouse, if filing
D YES
D NO
Go to #10
Go to #15

DYES
Go to #15

ONO
Go to #11

D YES
Go to #15

O NO
Go to #11

DYES
Go to (b)

ONO
Go to (c)

D YES
Go to (b)

O NO
Go to (c)

You
Are you a United States citizen by birth?
Are you a naturalized United States citizen?

11. (a) Are you an American Indian born outside the United
States?

DYES
Go to #15

Page 4 of 24

Form SSA-8000-BK(03-2017) UF
11. (b) Check the block that shows your American Indian status.
You

Your Spouse, if filing

OAmerican Indian born in Canada

Go to#15
Member
of
a
Federally
recognized
Indian
Tribe;
O
Name of Tribe

OAmerican Indian born in Canada

Go to#15
Member
of
a
Federally
recognized
Indian
Tribe;
O
Name of Tribe

Go to#15

Go to#15

O Other American Indian
Explain in Remarks, then Go to (c)

O Other American Indian
Explain in Remarks, then Go to (c)

(c).Check the block below that shows your current immigration status

Your Spouse, if filing

You
D Amerasian Immigrant .
OLawful Permanent Resident
Refugee
D Date of entry:
Date status granted:
Asylee
0
Conditional Entrant
D Date status granted:

O Parolee for One Year
OCuban/Haitian Entrant
Deportation/Removal Withheld
D Date:

Go to#12
Go to#12

OAmerasian Immigrant

Go to #12

O Lawful Permanent Resident

Go to#12

Go to#14

Refugee
D Date of entry:

r," to #14

Go to#14

0Asylee
Date status granted:

Go to#14

Conditional Entrant
D Date status granted:

Go to#14

Go to#14
Go to#14
Go to#14
Go to#14

00ther
Explain in Remarks, then Go to(d)

OParolee for One Year

Go to#14

OCuban/Haitian Entrant

Go to #14

Deportation/Removal Withheld
D Date:

Go to#14

0ther
0
Explain in Remarks, then Go to(d)

(d) If you have status, or have applied for status as the spouse, child, or parent of a child of a US citizen, or lawfully
admitted permanent resident alien, Go to#13; otherwise Go to#15.
12. If you are lawfully admitted for permanent residence:

Your Spouse
(month, day, year)

You
(month, day, year)

(a) Date of Admission

ONO
DYES
Go to(d)
Go to (c)
Give
the
following
information
about
the
person,
institution,
or
group,
then
Go to (d):
(c)
(c)
Name
(b) Was your entry into the United States sponsored
by any person or promoted by an institution or group?

DYES
Go to(c)

ONO
Go to (d)

Address
Telephone Number

You
Status:
(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?

Your Spouse, if filing
Status:

(month, day, year)

(month, day, year)
From:

From:

To:

To:

Go to(e)

Form SSA-8000-BK (03-2017) UF
12.

(e) If filing as an adult, did your parents ever work in the
United States before you were age 18?

D YES
Go to (f)

You

ONO
Go to#14

Page 5 of 24
Your Spouse, if filing
O NO
D YES
Go to#14
Go to (f)

(f) Name and Social Security Number of parent(s) who worked.
Name

Social Security Number

Name

Social Security Number
You

13.
(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?
14.

Are you, your spouse, or parent an active duty member or
a veteran of the armed forces of the United States?

Your Spouse, if filing

[}Jo

DYES
Go to (b)

ONO
Go to #15

DYES
Go to (b)

Go to#15

DYES

ONO

Go to#14

Go to#15

Go to#14

Go to#15

DYES

ONO
Go to#15

DYES

ONO
Go to#15

DYES

ONO

Explain in
#5960(b ). then
Go to#15
(month, day, year)

Explain in
#5960(b), then
Go to#15
(month, day, year)

(b) Have you lived outside of the United States since
then?

D YES

DYES

(c) Give the dates of residence outside the United States.

From:

Go to#16
Go to (c)
(month, day, year)
From:

To:

To:

15. (a) When did you first make your home in the United
States?

16. (a) Have you been outside the United States (the 50
states, District of Columbia and Northern Mariana
Islands) 30 consecutive days prior to the filing date?
(b) Give the date (month, day, year) you left the United
States and the date you returned to the United States.

D NO

Go to (c)
Go to#16
(month, day, year)

DYES

ONO

Go to (b)

Go to#17

DYES
Go to (b)

Date Left:

Date Left:

Date Returned:

Date Returned:

D NO

ONO
Go to#17

IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #17.
IF YOU ARE MARRIED AND YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY INCOME AND
YOU LIVED TOGETHER AT ANY TIME SINCE THE FIRST MOMENT OF THE FILING DATE MONTH, GO TO
#17; OTHERWISE GO TO #18.
17. (a) Is your spouse/parent the sponsor of an alien who is
eligible for supplemental security income?
(b) Eligible Alien's Name

18.

(a) Do you have any unsatisfied felony warrants for your
arrest?

D YES Go to (b)

D No

Go to#18

Eligible Alien's Social Security Number
Go to#18
Your Spouse, if filing

You
D YES

ONO

Go to (b)

Go to#19

Name of State/Country

D YES
Go to (b)

ONO
Go to #19

Name of State/Country

(b) In which sState or cCountry was this warrant issued?
Go to (c)

Go to (c)

Form SSA-8000-BK (03-2017) UF

18.

DYES

(c) Was the warrant satisfied?

Go to (d)

You
ONO

Go to #19

(month, day, year)

(d) Date warrant satisfied

Page 6 of 24
Your Spouse, if filing
ONO
DYES
Go to #19
Go to {d)
(month, day, year)

PART 2 - LIVING ARRANGEMENTS - The questions in this section refer to the signature date.
19. Check the block which best describes your present living situation:
Since (month, day, year)
D Household
D Non-Institutional Care
D Institution
D Transient or homeless

Since (month, day, year)

Since (month, day, year)
Since (month, day, year)
INSTITUTION

Go to #24
Go to #22
Go to #20
Go to #37

20. Check the block that identifies the type of institution where you currently reside, then Go to #21:
D School

D

Rehabilitation Center

D Hospital

D

Jail

D Rest or Retirement Home

D Other (Specify)

D Nursing Home

21. Give the following information about the INSTITUTION:
(a) Name of institution:

(b) Date of admission:

(c) Date you expect to be released from this institution:
NON-INSTITUTIONAL CARE
22. Check the block that best describes your current residence, then Go to #23:

Go to #37

D Foster Home J D Group Home j D Other (Specify)

23. Give the following information about your Noninstitutional Care:
(a) Name of facility where you live:

(b) Name of placing agency
Address

Telephone Number
(c) Does this agency pay for your room and board?
DYES Go to #37

D NO If NO, who pays?

Go to #37

Form SSA-8000-BK (03-2017) UF

Page 7 of 24
HOUSEHOLD ARRANGEMENTS

24. Check the block that describes your current residence, then Go to #25:
D

House

D Mobile Home

D Apartment

D Houseboat

D Room (private home)

D Other (Specify)

D Room (commercial establishment)
25. Do you live alone or only with your spouse?

D NO Go to #26

D YES Go to #27
26. (a) Give the following information about everyone who lives with you:
Name

Relationship

If Under 22
Public
Blind or
Sex Birthdate
Social Security
Assistance
Disabled Married Student
Number
YES NO M F mm/dd/yy YES NO YES NO YES NO
D

D DD

D D D D D D

D

D DD

D

D

D D D D

D

D DD

D D

D D D D

D

D DD

D

D D D D D

D

D

D

D D D D D

D

D DD

�

D

D D D

D D D

If anyone listed is under age 22 and not married, Go to (b); otherwise, Go to #27.
(b) Does anyone listed in 26(a) who is under age 18, OR
between ages 18-22 and a student, receive income?
(c) Child Receiving Income

DYES Go to (c)

D NO Go to #27
Monthly Amount

Source and Type

$

$

$

$

$

$

Form SSA-8000-BK (03-2017) UF
27. (a) Do you (or does anyone who lives with you) own or
rent the place where you live?

Page 8 of 24
O YES Go to #28

O No Go to (b)

(b) Name of person who owns or rents the place where you live
Address

Telephone Number
(c) If you live alone or only with your spouse, and do not own or rent, Go to #37; otherwise, Go to #31.
28.
(a) Are you (or your living with spouse) buying or do you
own the place where you live?
(b) Are your parent(s) buying or do they own the place
where you live?

0

YES
Go to (c)

0

YES

Go to (c)

0

No
If you are a child living with
your parent( s) Go to (b);
otherwise Go to #29
ONO Go to #29

(c) What is the amount and frequency of the mortgage payment?
Amount:
$
Frequency of Payment:
Go to (d)
(d) If you are a child living only with your parents, or only with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living alone or with your spouse, Go to #37;
otherwise Go to #31.
29.
(a) Do you (or your living with spouse) have rental liability
for the place where you live?
(b) Does your parent(s) have rental liability?

0

0

YES
Go to (d)

YES

Go to (d)

ONo
If you are a child living with
your parent( s) Go to (b );
otherwise Go to (c)
ONO Go to (c)

(c) Does anyone who lives with you have rental liability for the place where you live?
Go to #30

O YES Give name of person with rental liability:

0

Go to #31

NO Give name of person with home ownership:

(d) What is the amount and frequency of the rent payment?
Amount:
$
Frequency of Payment:
Go to #30
30. a) Are you (or anyone who lives with you) the parent or
child of the landlord or the landlord's spouse?

0

YES Go to (b)

ONO Go to (c)

(b) Name of person related to landlord or landlord's spouse
Relationship
Name and address of landlord (include telephone number and area code, if known):

(c) If you are a child living only with your parents, or only with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living alone or with your spouse, Go to #37.

Page 9 of 2 4

Form SSA-8000-BK(03-2 017) UF
31. (a) Does anyone living with you contribute to the
household expenses?(NOTE: See list of household
expenses in #36)

DYES Go to(b)

(b) Amount others contribute: $
32 . (a) Do you eat all your meals out?

D NO

Go to #32
Go to #32

(b) Do you buy all your food separately from other
household members:

DYES Go to #33

D NO Go to(b)

DYES Go to #33

D NO Go to #33

33. Do you contribute to household expenses?

Go to #34

D YES Average Monthly Amount: $

D NO Go to #34

34 . (a) Do you have a loan agreement with anyone to repay
D NO Go to #34(d)
D YES Go to(b)
the value of your share of the household expenses?
(b) Give the name, address and telephone number of the person with whom you have a loan agreement :

(c) Will the amount of this loan cover your share of the
household expenses?

DYES Go to #37

D NO Go to(d)

(d) If you contribute toward household expenses and you answered "NO" to both 32(a) &(b), Go To #35. If you
answered "YES" to either 32(a) or 32(b), Go to #36.
If you do not contribute toward household expenses, go to #37.
35. (a) Is part or all of the amount in #33 just for food?

D YES

Give Amount: $

Go to(b)

D

NO Go to(b)

Go to #36

D

NO Go to #36

(b) Is part or all of the amount in #33 just for shelter?

D YES

Give Amount: $

36. What is the average monthly amount of the following household expenses:
(Show average over the past 12 months unless you have been residing at your present address less than 12
months. If so, show average for the months you have resided at your present address.)
AVERAGE MONTHLY AMOUNT

CASH EXPENSES
Food (complete only if #32(a) &(b) are answered NO)

$

Mortgage or Rent

$

Property Insurance(if required by mortgage lender)

$

Real Property Taxes

$

Electricity

$

Heating Fuel

$

Gas

$

Sewer

$

Garbage Removal

$

Water

$

TOTAL

$

Go to #37

Page 10 of 24
Form SSA-8000-BK(03-2017) UF
37. (a) Does anyone who does NOT LIVE with you pay for, or provide you or your household(if applicable), any of your
food or shelter items?
DYES

Name of Provider (Person or Agency)
List of Items
Monthly Value: $

D NO

Go to (b)
(b) Does anyone who does NOT LIVE with you give you, or your household(if applicable), money to pay for any of
your or your household's food or shelter items?
DYES

Name of Provider (Person or Agency)
List of Items
Monthly Value: $

D NO

Go to #38

38.
(a) Has the information given in #19-37 been the same
since the first moment of the filing date month?

b) Do you expect any of this information to change?

D

D

YES
Go to(b)

D No

YES

D No
Go to #39

Explain in Remarks,
then Go to(b)

Explain in Remarks,
then Go to #39

PART 3 - RESOURCES - The questions in this section pertain to the first moment of the filing date month.
39 (a) Do you own, or does your name appear (alone or with
40.
D YES
any other person's name) on the title of any vehicles
.
Go to(b)
(auto, truck, motorcycle, camper, boat, etc.)?

(b) Owner's Name

Description
(Year, Make & Model)

40
44 .(a) Do you own or are you buying any life insurance
policies?

Your Spouse
D NO
ONO
DYES
Go to #4041 Go to(b)
Go to #4041

You

Used For

DYES
Go to(b)

You

Current Market
Amount O wed
Value
$

$

$

$

$

$

$

$

D NO
Go to 41
45

Your Spouse
DYES
ONO
Go to #41 45
Go to(b)

Form SSA-8000-BK (03-2017) UF
40
44.
(b) Owner's Name

Page 11 of 24
Name of Insured

Name & Address of
Insurance Company

Cash Surrender Value

Date of Purchase

Policy Number

Policy (#1)
Policy (#2)
Policy (#3)

Face Value

Dividends
YES

NO

Accumulations
YES

NO

Policy (#1)
Policy (#2)
Policy (#3)
(c) Loans Against Policy?
DYES
Policy Number:
Amount:$
D NO
41 46. (a) Do you (either alone or jointly with any other person)
own any:

Go to #4145
Your Spouse

You
YES

NO

YES

NO

Life estates or ownership interest in an unprobated
estate?

D

D

D

D

Items acquired or held for their value as an investment?

D

D

D

D

(b) Give the following information for any "Yes" answer in #4146 (a); otherwise, Go to #42 47.
Owner's Name

Value

Name of Item

Amount Owed

$

$

$

$

$

$

$

$

Name & Address of Bank or
Other Organization

Page 12 of 24

Form SSA-8000-BK (03-2017) UF
42. (a) Do you own, or does your name appear on (either
alone or with any other person's name) any of the
following items?

Your Spouse

You
YES

NO

YES

NO

Cash at home, with you, or anywhere else

D

D

D

D

Financial Institution Accounts

D

D

D

D

Checking

D

D

D

D

Savings

D

D

D

D

Credit Union

D

D

D

D

Christmas Club

D

D

D

D

Time Deposits/Certificates of Deposit

D

D

D

D

Individual Indian Money Account

D

D

D

D

Other (Including IRAs and Keough Accounts)

D

D

D

D

(b) If all the items in #42(a) are answered "NO", Go to #43 42(c). For any "YES" answer, give the following information:
Owner's/Trustee's
Name

Name & Address of Bank or
Other Organization

Value

Name of Item

Identifying
Number

$

$

$

$

43
42. (a)(c) Do you give us permission to obtain any financial
records from any financial institution?

DYES
Go to (b)43

43(a) (b) Do you own or does your name appear on any of the
following items:

Your Spouse, if filing
NO
ONO
D
D YES
Go to (b)43 Go to (b)43
Go to (b)43

You

Your Spouse

You
YES

NO

YES

NO

Stocks or Mutual Funds

D

D

D

D

Bonds (Including U.S. Savings Bonds)

D

D

D

D

Promissory Notes

D

D

D

D

Trusts

D

D

D

D

Other items that can be turned into cash

D

D

D

D

Form SSA-8000-BK (03-2017) UF
Page 13 of 24
43. (b)
(c) If all the items in #43(a)(b) are answered "NO", Go to #44. For any "YES" answer, give the following information:
Owner's/Trustee's
Name

Name of Item

Value

Identifying
Number

Name & Address of Bank or
Other Organization

$

$

$

$

44

41. (a) Do you own, or does your name appear (alone or with

You

any other person's name) on any land, houses,
buildings, real property, property in foreign country,
DYES
equipment, mineral rights, items in a safe deposit box,
Go to (b)
assets set aside for emergencies or heirs, or any other
property of any kind that has not been shown
anywhere else on the application

Your Spouse

DNO
DYES
Go to # 42 45Go to (b)

ONO
Go to #42 45

(b) Describe the property (including size, location address, and how it is used. If the property is not used now, when was it
last used? Do you plan to use the property in the future?
Item #1

Item #2

Owner's Name

Estimated
Tax Assessed
Current Market
Value
Value

Mortgage

Owed on Item

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

45. (a) Have you or your spouse acquired any assets since
the first moment of the filing date month?
(b) Explain:

DYES Go to (b)

D NO Go to (c)

Form SSA-8000-BK {03-2017) UF
45. (c) Has there been any increase or decrease in the value
of you or your spouse's resources since the first
moment of the filing date month?
(d) Explain:
46.49 (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?
(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?

Page 14 of 24
D NO Go to #46

DYES Go to (d)

Your Spouse

You
ONO

DYES

DYES

Go to (bl

Go to (b
D NO

DYES

ONO

DYES

ONO

IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #47 50 .
(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)
Sales Price or Other Consideration

Are Other Consideration
Do You Still Own Part of
or Proceeds Expected?
the Property?
Explain.

Item (#1)
Item (#2)
Item (#3)
Sold on Open Market?

Given Away?

Traded for Goods/
Services?

Item (#1)

DYES

D NO

DYES

D NO

DYES

D NO

Item (#2)

DYES

D NO

DYES

D NO

DYES

D NO

Item (#3)

D YES

D NO

DYES

D NO

DYES

D NO

Form SSA-8000-BK(03-2017) UF
47
. (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 items mentioned in #40 39 and #42-46
40-46.
(b) DESCRIPTION(Where appropriate, give name
& address of organization and account/ policy
number.)
Item(#1)
$

Item(#2)

Page 15 of 24
Your Spouse

You
ONO
Go to #48

OYES
Go to(b)

When Set Aside
(month, day, year)

Value

ONO
Go to #48

O YES
Go to(b)

Owner's Name

$

For Whose Burial

Is Item Irrevocable?

Will Interest Earned or Appreciation in
Value Remain in the Burial Fund?

Item(#1)

OYES

O NO

O YES
Go to #48 49

ONO
Explain in(c)

Item(#2)

O YES

O NO

OYES
Go to #48 49

ONO
Explain in(c)

(c) Explanation

48
. (a) Do you own any cemetery lots, crypts, caskets, vaults,
O YES
urns, mausoleums, or other repositories for burial or
Go to(b)
any headstones or markers?

(b) Owner's Name

Description

Your Spouse

You
ONO
Go to #49

For Whose Burial

ONO
Go to #49

O YES
Go to(b)

Relationship to You or Current Market
Value
Your Spouse
$

$

$

Go to #49

Page 16 of 24

Form SSA-8000-BK (03-2017) UF
PART 4- INCOME
49. 50 (a) Since the first moment of the filing date month, have
you ( or your spouse) received or do you (or your
spouse) expect to receive income in the next 14
months from any of the following sources?
State or Local Assistance Based on Need
Refugee Cash Assistance
Temporary Assistance for Needy Families
General Assistance from the Bureau of Indian Affairs
Disaster Relief
Veteran Benefits Based on Need (Paid Directly or
Indirectly as a Dependent)
Veteran Payments Not Based on Need (Paid Directly or
Indirectly as a Dependent)
Other Income Based on Need
Social Security
Black Lung
Railroad Retirement Board Benefits
Office of Personnel Management (Civil Service)
Pension (Foreign Military, State, Local, Private, Union,
Retirement or Disability)
Military Special Pay or Allowance
Unemployment Compensation
Workers' Compensation
State Disability
Insurance or Annuity Payments
Dividends/Royalties
Rental/Lease Income Not from a Trade or Business
Alimony
Child Support
Other Bureau of Indian Affairs Income
Gambling/Lottery Winnings
Other Income or Support

Your Spouse

You
YES

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

NO

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

YES

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

NO

D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D

Form SSA-8000-BK (03-2017) UF
49.50.(b) Give the following information for any block checked YES in #4950(a); otherwise, Goto #5051
Person
Receiving
Income

Date
Source (Name, Address of
Amount Frequency of
Expected or
Person.Bank,
Received
Payment
Received
Organization, or Company)

Type of Income

Page 17 of 24

Identifying
Number

$

$

$
IF YOU EVER RECEIVED SSI BEFORE, GO TO #50;51 OTHERWISE GO TO #5152
50. 51

Are any overpayments being collected from benefits you
receive from the Social Security Administration, Railroad
Retirement Board, Office of Personnel Management,
Veterans' Affairs, Military Pensions, Military Special Pay
Allowances, Black Lung, Workers' Compensation, or State
Disability or Unemployment Benefits?

51
52. Since the first moment of the filing date month, have you
received or do you expect to receive any meals or other
gifts which are not cash?

O YES
Explain in
Remarks,
then Go to
#5152
O YES
Explain in
Remarks,
then Go to
#5253

52 (a) Have you (or your spouse) received wages or sick pay
O YES
53.
since the first moment of the filing date month through
Go to (b)
the current month?

You
Your Spouse
ONO
ONO
O YES
Go to #5152 Explain in
Go to #5152
Remarks,
then Go to
#5152
ONO
O YES
Go to #5253 Explain in
Remarks,
then Go to
#5253

ONO
Go to #5253

O NO
Go to (e)

ONO
Go to (e)

O YES
Go to (b)

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

Go to (c)

Your Spouse

Go to (c\
(c)

Date last worked
(month, day, year)

Date last paid
(month, day, year)

Date next paid
(month, day, year)

You
Your Spouse
Your Amount
(d) Total monthly wages received (before any deductions) $

(e) Do you (or your spouse) expect to receive any wages
in the next 14 months?

OYES
Go to (f)

Your Spouse's Amount
$

You
Your Spouse
ONO
ONO
O YES
Go to #5354 Go to (f)
Go to #5354

Form SSA-8000-BK (03-2017) UF
52. 53(f) Name and address of employer if different from #52(b) (include telephone number, if known)

Page 18 of 24

You

Your Spouse

(g) Give the following information:
Rate of Pay

Amount Worked Per
Pay Period

How Often Paid

Pay Day or
Date Paid

Date Last Paid
(month, day, year)

You
Your
Spouse
(h) Do you expect any change in wage information
provided in #5253(g)

O YES
Go to (i)

Your Spouse
You
ONO
O NO
O YES
Go to #5354
Go to #5354 Go to (i)

O YES
Go to (b)

Your Spouse
You
ONO
O NO
O YES
Go to #5455
Go to #5455 Go to (b)

(i) Explain Change:
You

Your Spouse

53.54 (a) Have you been self-employed at any time since the

beginning of the taxable year in which the filing date
month occurs or do you expect to be self-employed in
the current taxable year?

(b) Give the following information; then Go to #5455
Date(s) Self-Employed

Type of Business

Date(s) Self-Employed

Type of Business

5455.
If you or your spouse are blind or disabled, do you have
any special expenses that you paid which are necessary
for you to work?

Last Year's:
Last Year's:
Gross Income Net Profit

Last Year's:
Net Loss
$

$

This Year's:
This Year's:
Gross Income Net Profit

$

This Year's:
Net Loss

$

$

$

Your Spouse
You
ONO
O YES
O YES
ONO
G o to #5556
Explain in
Go to #5556 Explain in
Remarks,
Remarks,
then Go to
then Go to
#5556
#5556

Form SSA-8000-BK(03-2017) UF
55.56(a) Doe
s your spouse/parent who lives with
you have to
pay court-ordered support?

Page 19 of 24
D NO Go to NOTE

DYES Go to(b)

(b) Give amount and frequency of court-ordered support payment.
Amount $
Frequency of Payment:
Go to(c)
(c) Give the following information about the person who receives these payments:
Name:
Address:

NOTE: IF YOU ARE FILING AS A CHILD AND YOU ARE EMPLOYED OR AGE 18- 22(WHETHER EMPLOYED
OR NOT), GO TO #5657; OTHERWISE. GO TO #5758.
56.57 (a) Have you attended school regularly since the filing
D NO Go to(b)
DYES Go to(d)
date month?
(b) Have you been out of school for more than 4 calendar
months?
(c) Do you plan to attend school regularly during the next
4 months?
(d) Name of School

D NO Go to(c)

DYES Go to(c)
DYES Explain absence in
Remarks and Go to(d)

D NO Go to #5758

Name of School Contact

Dates of Attendance
To
From

Phone Number

Hours Attending or
Planning to Attend

Course of
Study

PART 5 • POTENTIAL ELIGIBILITY FOR FOOD STAMPS/MEDICAL ASSISTANCE/OTHER BENEFITS· If a
California resident, Skip to #5859
Your Spouse, if filing
You
57
58. (a) Are you currently receivingSNAP benefits food stamps DYES
ONO
DYES
DNO
Go to(c)
Go to(b)
Go to(b)
Go to(c)
(formerly food stamps)?
(b) Have you received a recertification notice within the
past 30 days?

DYES
Go to(e)

DYES
(c) Have you filed for SNAP food stamps in the last 60 days?
Go to(d)
(d) Have you received an unfavorable decision?

DYES
Go to(e)

D YES
DNO
Go to #5859 Go to(e)
DNO
Go to(e)

DYES
Go to(d)

DYES
DNO
Go to #5859 Go to(e)

ONO
Go to #5859
ONO
Go to(e)
ONO
Go to #5859

(e) If everyone in the household receives or is applying for SSI, Go to(f); otherwise Go to #58.
(f) May I take yourSNAP food stamp application
today?
(g)

Explanation:

DYES
Go to #5859

ONO
DYES
Explain in(g Go to #58

ONO
Explain in(g)

Page 20 of 24
Form SSA-8000-BK (03-2017) UF
58.59 You may be eligible for Medicaid. However, you must help your State identify other sources that pay for medical
care. Also, you must give information to help the State get medical support for any child(ren) who is your legal
responsibility. This includes information to help the State determine who a child's father parent is. If you want Medicaid,
you must agree to allow your State to seek payments from sources, such as insurance companies, that are available to
pay for your medical care. This includes payments for medical care for you or any person who receives Medicaid
and is your legal responsibility. The State cannot provide you Medicaid if you do not agree to this Medicaid
requirement. If you need further information, you may contact your Medicaid Agency.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to (b).
(a) Do you agree to assign your rights (or the rights of
anyone for whom you can legally assign rights) to
payments for medical support and other medical care
to the State Medicaid agency?
(b) Do you, your spouse, parent or stepparent have any
private, group, or governmental health insurance that
pays the cost of your medical care? (Do not include
Medicare or Medicaid.)

DYES
Go to (b)
DYES
Go to (c)

Your Spouse, if filing
ONO
DYES
NO
D
Go to #5960
Go to #5960 Go to (b)

You

O NO
Go to (c)

ONO
Go to (c)

D YES
Go to (c)

(c) Do you have any unpaid medical expenses for the 3
ONO
DYES
D YES
D NO
months prior to the filing date month?
Go to #5960 Go to #5960 Go to #5960
Go to #5960
59.60(a) Have you ever worked under the U.S. Social Security
D NO Go to (b)
DYES Go to (b)
System?
(b) Have you, your spouse, or a former spouse (or parent
if you are filing as a child) ever:

Your Spouse/
Parent

You
YES

NO

YES

NO

Filed for
Benefits
YES

NO
D

Worked for a railroad

D

D

D

D

D

Been in military service

D

D

D

D

D

Worked for the Federal Government

D

D

Worked for a State or Local Government

D

D

D
D

D
D

D

D
D
D

Worked for an employer with a pension plan

D

D

D

D

D

D

Belonged to union with a pension plan

D

D

D

D

D

D

Worked under a Social Security system or pension plan of
a country other than the United States?

D

D

D

D

D

D

D

(c) Explain and include dates for any "Yes" answer given in #14 or #59 60(a); otherwise Go to #60.61
You

Your Spouse, if filing/Your Parent, if filing as a child:

PART 6 - MISCELLANEOUS - (Answer #6061 ONLY IF YOU AR E APPLYING ON BEHALF OF SOMEONE ELSE:
OTHERWISE GO TO #61.62
Your Social Security Number
Relationship to Claimant
60.61 (a) Name of Person/Agency Requesting
(or EIN)
Benefits.
(b) If SSA determines that the claimant needs help
managing benefits, do you wish to be selected
representative payee?

DYES

D NO
(Explain in Remarks)

Page 21 of 24
Form SSA-8000-BK (03-2017) UF
PART 7 -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.)

PART 8 -IMPORTANT INFORMATION AND SIGNATURES
61. 62 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 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 canceling 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.
62. I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
63 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.
Date (month, day, year)
Your Signature (First name, middle initial, last name) (Sign in ink.)

Telephone Number(s) where we can
contact you during the day:
Spouse's Signature (Sign only if applying for payments.) (First name. middle initial, last name) (Sign in ink.)

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

O Standard notice First Class
O Standard notice First-Class with a follow-up phone call
O Standard notice & data CD by First-Class
O Standard notice Certified

O Standard & Braille notices by First-Class
O Standard & large print notices
O Standard notice & audio CD

Form SSA-8000-BK (03-2017) UF
Page 22 of 24
64
WITNESS
65.
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
Address (Number and Street, City, State, and ZIP Code)

2. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)

Form SSA-8000-BK (03-2017) UF

Page 23 of 24

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 mail your request to:

For general information about Social Security, visit our website at www.socialsecurity.gov on the Internet.
We will process your application for Supplemental Security Income as quickly as possible. If you have trouble getting any
information or records we have asked for, please contact us and we will help you.
You should hear from us within __ days after you have given us all the information we requested. Some claims may
take longer if additional information is needed. If you do not get a check or notice of determination within that time,
please get in touch with us.
See Revised Privacy Act
Privacy Act Statement
Collection and Use of Personal Information Statement Attached
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this information. We will use this
information to help us determine your entitlement to benefits. Furnishing us this information is voluntary. However, failing
to provide us with all or part of the requested information may prevent us from making an accurate and timely decision on
your claim, which may result in the loss of payments. We rarely use the information you supply for any purpose other than
for determining problems in Social Security programs. 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 Medicare 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 the 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. 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
use of routine uses for this information is available in System of Records Notices 60-0089, Claims Folder System and
60-0050, Completed Determination-Continuing Disability Determinations. These notices, additional information regarding
this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or any
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�
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 40 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.
REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income (SSI) check is based on the information told to us. You must tell Social
Security every time there is a change-while we process your application AND if you start receiving SSI. Remember, a
change may make the SSI monthly payment bigger or smaller. Report changes in income of your ineligible spouse husband/
wife or child who lives with you or your sponsor or sponsor's spouse, if you are an alien. You must also
report changes in the things of value that these people own. You must also report changes in income, school attendance
and marital status of ineligible children who live with you. 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.
HOW TO REPORT
You may make your reports:
• By telephone at the telephone number shown above or call us toll free at 1-800-772-1213 (TTY 1-800-325-0778)
or
• In person or
• By mail at the address shown above.

Page 24 of 24

Form SSA-8000-BK (03-2017) UF

O

CHANGES TO REPORT
WHERE YOU LIVE· You must report to Social Security if:
• You move.
• You leave the United States for 30 consecutive days.
• You are no longer a legal resident of the United
• You (or your spouse) leave your household for a
States
calendar month or longer. (For example, you enter a
hospital or visit a relative.)
• You are admitted to (for a calendar month or longer),
or released from, a hospital or nursing home, jail,
prison, or other correctional facility or other institution.

O

O

O
O
O

HOW YOU LIVE· You must report to Social Security:
• If anyone moves into or out of your household.
• Your marital status changes:
- You get married, separated, divorced, or your
• If the amount of money you pay toward household
marriage is annulled.
expenses changes.
- You begin living with someone as a married
• Births and deaths of any people with whom you live.
couple. husband and wife.
• Your spouse or former spouse dies.
INCOME· You must report to Social Security if you, your spouse/your parent(s):
• Start work or stop work.
• Start to receive money (or checks or any other type
of payment) from someone or someplace.
• Earn more or less money. (Keep all paystubs and
provide them to SSA when requested.)
• Have a change in the amount of money you receive.
• Begin to receive child support payments or those
• Become eligible for benefits other than SSI.
payments go up or down.
• Win money from gambling or a lottery.
HELP YOU GET FROM OTHERS· You must report to Social Security if:
• Someone stops helping you.
• The amount of help (money or food, or payment of
household expenses) you receive goes up or down.
• Someone starts helping you.
THINGS OF VA� UE THAT YOU OWN· You must report to Social Security if:
• The value of things that you own goes over $2000
• You sell or give any thing of value away.
when you add them all together ($3000 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:
• You go to work.
• Your condition improves or your doctor says you
can return to work.

O IF YOU ARE THE PARENT, STEP PARENTS STEPPARENT, OR REPRESENTATIVE PAYEE FOR A CHILD UNDER 18 ·
to Social Security must be made if:
A report
• There is a change in any income the child, his or her
parent(s), step parent, stepparent or brother(s) or
sister(s) receive.
• There is a change in the student status of the child's
brother(s) or sister( s).

O
O
O

D

• There is a change in his or her parents' or step
parents' stepparents' marriage, a change in the
value of anything they own, or a change in their
residence.

YOU ARE UNMARRIED AND UNDER AGE 22 • A report to Social Security must be made if:
• You start or stop school
• You start or stop working
• You get married or divorced
YOUR IMMIGRATION STATUS CHANGES• You must report any changes to Social Security.
YOU ARE SELECTED AS A REPRESENTATIVE PAYEE· You must report to Social Security if:
• You will no longer be able or no longer wish to act as
• The person for whom you receive SSI checks has
that person's representative payee.
any 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.)
FELONY OR ARREST WARRANT· You must report to Social Security if you have a felony or arrest warrant
for:
• Escape from custody
• Flight to avoid prosecution or confinement, or
• Flight-Escape

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on a claim for
Supplemental Security Income (SSI) or could result in the loss of benefits.
We will use the information to determine SSI eligibility and to calculate SSI payment amounts.
We may also share your information for the following purposes, called routine uses:


To third party contacts, where necessary, to establish or verify information provided by
representative payees or payee applicants; and



To State agencies, to enable them to assist in the effective and efficient administration of
the SSI program.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0103, entitled SSI Record and Special Veterans Benefits,
as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full
listing of all our SORNs, is available on our website at www.ssa.gov/privacy.