SSA-8203-BK Current Version

Form SSA-8203-BK (10-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 12
OMB No. 0960-0416

Update

For Official Use Only
STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR
SUPPLEMENTAL SECURITY INCOME PAYMENTS

EI SSN
Spouse's Name

Name and Address
Spouse's SSN
Click the Ones That Apply
C

NC

M

N

FS-APP

FS-REF

Interviewer's Initials

DO Code

Date Received

When answering 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)

DATE YOU MOVED

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 (MM/DD/YYYY)

No

Yes

No

DATE(S) RETURNED (MM/DD/YYYY)

4. Since the date above, have you spent a full calendar month in a hospital, nursing home, or other
institution? If "yes," please give:
NAME OF INSTITUTION

Yes

DATE ENTERED (MM/DD/YYYY)

DATE LEFT (MM/DD/YYYY)

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

Hospital

School

Rehabilitation Center

Other

6. Since the date above, has anyone moved into or out of the place where you live? (including births and
Yes
No
deaths) If "yes," please give:
BLIND OR
INELIGIBLE CHILD
DISABLED
DATE
DATE
NAME
RELATIONSHIP AGE
MOVED IN MOVED OUT STUDENT MARRIED INCOME
YES NO
YES NO YES NO YES NO

(If Yes, Explain)

Form SSA-8203-BK (10-2018)

Page 2 of 12
LIVING ARRANGEMENTS (continued)

7. Do any other people live in the same household with you or your spouse? If "yes," please give the
Yes
No
following information about them (including children):
BLIND OR
INELIGIBLE CHILD
DISABLED
AGE AND/OR
NAME
RELATIONSHIP
DATE OF BIRTH
STUDENT MARRIED INCOME
YES NO
YES NO YES NO YES NO

(If Yes, Explain)
8. Do all of the people who live with you receive public assistance payments? (For example, welfare, TANF,
VA pension, general assistance, SSI.)
9. 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

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)

LANDLORD'S
PHONE

MONTHLY
RENT

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

Yes

No

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,
sewage, or garbage collection services?

Yes

No

Yes

No

b. Help you pay the mortgage, rent, property insurance, property taxes, and/or sewage 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:
TYPE OF HELP

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

PHONE
NUMBER

MONTHLY MONTHS
AMOUNT RECEIVED

Form SSA-8203-BK (10-2018)

Page 3 of 12
LIVING ARRANGEMENTS (continued)

11. Since the date on page 1, did anyone give you gifts which are not cash?
If "yes," complete the following:
DESCRIPTION OF
ARTICLE

Yes

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

PHONE
NUMBER

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

No

a. Amounts for Past Months
NAME OF WORKER

GROSS WAGES
How Often
Amount
Paid

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

DATES OF
EMPLOYMENT
From:
To:
From:
To:

b. Estimates for Current and Future Months
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 SELFEMPLOYED
PERSON

TYPE OF BUSINESS

LAST YEAR'S
THIS YEAR'S ESTIMATED
NET
NET
GROSS
GROSS
INCOME
INCOME
INCOME (OR LOSS)
INCOME
(OR LOSS)

Yes

No

DATES OF SELFEMPLOYMENT
From:
To:
From:
To:

14. If you are disabled, do you have any special expenses that you paid that are related to your illness or
injury and which are necessary for you to work?

Yes

No

Form SSA-8203-BK (10-2018)

Page 4 of 12
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 INCOME

RECEIVED BY

AMOUNT

FREQUENCY

DATES RECEIVED
OR EXPECTED

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

From:
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

e. Christmas club accounts?

Yes

No

f. Savings certificates/certificates of deposit?

Yes

No

g. Promissory notes or IOU's?

Yes

No

h. Stocks or bonds?

Yes

No

i. Achieving A Better Life (ABLE) accounts?

Yes

No

j. Other items that can be cashed or sold?

Yes

No

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

OWNER(S) OF EACH TOTAL VALUE OF
ITEM
EACH ITEM

NAME AND ADDRESS OF BANK, COMPANY, OR
ORGANIZATION

Form SSA-8203-BK (10-2018)

Page 5 of 12
RESOURCES: THINGS YOU OWN (continued)

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?

Yes

No

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

POLICY NUMBER

NAME OF INSURED

TOTAL FACE
VALUE OF POLICY

NAME AND ADDRESS OF INSURANCE COMPANY

CASH
SURRENDER
VALUE

WHEN WAS THE
POLICY PURCHASED

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

19. 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.)?

Yes

No

If "yes," please give the following information:
NAME OF OWNER(S)

YEAR OF
VEHICLE(S)

MAKE AND MODEL

CURRENT MARKET
VALUE

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

Yes

No

AMOUNT OF
TAX ASSESSED
AMOUNT OWED ON
MORTGAGE PAYMENT
VALUE IF KNOWN
THE PROPERTY
(If any)

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

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

Form SSA-8203-BK (10-2018)

Page 6 of 12
RESOURCES: THINGS YOU OWN (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?

Yes

No

b. Other equipment (business or nonbusiness) or property of any kind (not already included on this form?

Yes

No

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

HOW MUCH IS OWED
ON EACH ITEM

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

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?
NAME OF OWNER

FOR WHOSE BURIAL

RELATIONSHIP TO
YOU OR YOUR
SPOUSE

Yes

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.)

Yes

No

If "yes," please give the following information:

DESCRIBE WHAT YOU HAVE SET ASIDE

VALUE

WHEN DID YOU
SET IT ASIDE
(MM/DD/YYYY)

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

IS IT IRREVOCABLE
YES

NO

NAME OF OWNER

FOR WHOSE BURIAL

NO

Form SSA-8203-BK (10-2018)

Page 7 of 12

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

Yes

No

Yes

No

You

Yes

No

Your Spouse

Yes

No

If "YES" to (A) or (B), complete the table. If "NO" to both, go to 24.
SOLD ON
OPEN
MARKET

GIVEN
AWAY

TRADED FOR GOODS/
SERVICES

DESCRIPTION OF PROPERTY

VALUE OF PROPERTY
AND/OR AMOUNT OF
CASH GIFT

DO YOU STILL OWN
THE PROPERTY?
YES

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

NAME AND ADDRESS OF PURCHASER OR
RECIPIENT

SALE PRICE OR OTHER
CONSIDERATION RECEIVED

DATE OF DISPOSAL

RELATIONSHIP TO OWNER

ARE ADDITIONAL CONSIDERATION OR PROCEEDS
EXPECTED? EXPLAIN

IF YES, EXPLAIN

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

Yes

No

Form SSA-8203-BK (10-2018)

Page 8 of 12

25.

You
a. Are you currently receiving food stamps?
If YES, go to "b." If NO, go to "c."
b. Have you received a recertification notice within the past 30 days?
If YES, go to "e." If NO, go to question 26.
c. Have you filed for food stamps in the last 60 days?
If YES, go to "d." If NO, go to "e."
d. Have you received a favorable decision?
If YES, go to question 26. If NO, go to "e."
e. Is everyone in the household applying for or receiving SSI?
If YES, go to "f." If NO, go to question 26.
f. May I take your food stamp application today?
If YES, go to question 26. If NO, explain in "g."

Your Spouse

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

g. Explanation

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 deceased?

Yes

No

You

28.
a. Do you have any unsatisfied felony warrants for your arrest?

Yes
Go to b

No

Name of State/Country

Your Spouse, if filing
Yes
No
Go to b
Name of State/Country

b. In which state or country was this warrant issued?
Go to c
c. Was the warrant satisfied?
d. Date warrant satisfied:

Yes
Go to d

Yes
Go to d

No

MM/DD/YYYY

MM/DD/YYYY

You

Your Spouse, if filing
Yes
No
Go to b

29.
a. Do you have any unsatisfied Federal or State warrants for
violating the conditions of probation or parole?

No

Go to c

Yes
Go to b

No

Name of State/Country

Name of State/Country

b. In which state or country was the warrant issued?
Go to c
c. Was the warrant satisfied?
d. Date warrant satisfied:

Yes
Go to d

No

MM/DD/YYYY

Go to c
Yes
Go to d

No

MM/DD/YYYY

Form SSA-8203-BK (10-2018)

Page 9 of 12

Remarks:

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

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

Area Code and Telephone Number Where You Can Be
Reached
Your full name (First name, middle initial, last name)
Please print here

Please sign here

Date

Form SSA-8203-BK (10-2018)

Page 10 of 12
RIGHTS AND RESPONSIBILITIES

Name

Social Security Number

Date

Name

Social Security Number

Date

Telephone Number (include
area code) to call if you have a
question or something to report

Social Security Office you may visit in person or send in your request:

Privacy Act Statement
Collection and Use of Personal Information
Section 1611(c)(1) of the Social Security Act, as amended, allows us to collect this information. We will use the information you
provide to attempt to determine if you continue to be eligible for supplemental security income payments.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making
an accurate decision on your continuing eligibility for benefits and could result in the loss of benefits.
We rarely use the information you supply for any purpose other than what we state 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of
our programs (e.g., to the Bureau of the Census and to private entities under contract with us.)
A list of when we may share your information with others, called routine uses, is available in our Privacy Act System of Records
Notices entitled Claims Folder System (60-0089) and Supplemental Security Income Record and Special Veterans Benefits
System (60-0103). Additional information about these and other system of records notices and our programs is available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.
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.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 or the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB)
control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-8203-BK (10-2018)

Page 11 of 12
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 (10-2018)

Page 12 of 12
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.

• Changes in your marital status:

• If your former spouse dies.

• You get married, separated, divorced, or your marriage
is annulled.
• You separate from your spouse or start living together
again after a separation.

• Births and deaths of any people with whom you live.

• You begin living with someone as husband and wife.

• If the amount of money you pay toward household
expenses changes.

• 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 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 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(s), ask
your parents to report if they have a change in income, a
change in their marriage, a change in the value of
anything they own, or either has a change in residence.

• There are changes in the income, school attendance (if
between the ages of 18 and 21), or marital status of
ineligible children who live in your household.

• 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.