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

Application for Supplemental Security Income (SSI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0229 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-8000-BK Application for Supplemental Security Income--SSA-8000-BK (Paper Form) Form
SSA-8000-BK Application for Supplemental Security Income (SSI) SSA-8000-BK - Revised.pdf Form
SSA-8000-BK - Current.pdf SSA-8000-BK - Current IC Document

Information Collection (IC) Details

IC Title:	Application for Supplemental Security Income--SSA-8000-BK (Paper Form)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.305-.335 20 CFR 416.207

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8000-BK	Application for Supplemental Security Income (SSI)	SSA-8000-BK - Revised.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,941	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,941	3,400	17,541
Annual IC Time Burden (Hours)	14,310	2,324	11,986
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-8000-BK - Current	SSA-8000-BK - Current.pdf	09/26/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.