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

SSA will insert the following revised Privacy Act & PRA Statements 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 an accurate and timely decision on any claim for Supplemental
Security Income (SSI) or could result in the loss of benefits.
We will use the information you provide to determine SSI eligibility and to calculate SSI
payment amounts. We may also share you 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 Supplemental Security Income 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
October 31, 2019, at 84 FR 58422, and 60-0103, entitled Supplemental Security Income 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 of our SORNs, is available on our website at
www.ssa.gov/privacy.

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 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 1-800772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or
any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
or other aspects of this collection to this address, not the completed form.