Form SSA-8001-BK(revise Application For Supplemental Security Income

Form SSA-8001-BK (09-2019) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 12
OMB No. 0960-0444
Do Not Write in This Space

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
(Deferred or Abbreviated)

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.

DEFERRED
ABAP
SNAPSNAPSSA/APP
REFERRED
Filing Date (MM/DD/YYYY)
Receipt

Protective

Preferred Language:
Written:
Spoken:

TYPE OF CLAIM

Individual

Individual with
Ineligible Spouse

Couple

Child

Child with
Parent(s)

PART 1 - BASIC ELIGIBILITY - Answer the questions below beginning with the first moment of the filing date month.
1. First Name, Middle Initial, Last Name
1(a)

5. If filing as spouse or couple (a) Spouse's Name(s)
2(a)

3(a) If filing for child (b) Parent 1's Name(s)
(d) If filing for child (c) Parent 2's Name(s)

2. Sex
3. Birthdate
(b)
(MM/DD/YYYY)
Male
Female
6(a). Sex (b)
7(a). Birthdate
(MM/DD/YYYY)
Male
Female
6(b). Sex (b)
7(b). Birthdate
(MM/DD/YYYY)
Male
Female
6(c). Sex (e)
7(c). Birthdate
(MM/DD/YYYY)
Male
Female

(c)
4. Social Security Number

8 (a). Social Security Number(s)
(c)

8
(b). Social Security Number(s)
(c)

8(f)
(c). Social Security Number(s)

4.
8(d). Are you married?

(b)
(e) Date of Marriage

YES, complete (e) and (f)

(MM/DD/YYYY)

5.
NO, Go to (g)

(f). Are you and your spouse living together?
(c)
YES

NO If no, date you began living apart

5(a)
(g). Are you and another person living together in the same household and presenting to others or the community as a

married couple?
YES, provide the date holding out began (MM/DD/YYYY)

(b)
. Go to (h)*.

NO Go to #9.
*(h) Other person's name (First, middle initial, last)
*(b)
*Use SSA-4178 to develop the holding out relationship.

(c) Other person's Social Security Number

Form SSA-8001-BK (09-2019) UF

Page 2 of 12

6.
9. Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d).

(a) Your Other Name(s) (including Name at Birth)

Social Security Number

(b) Spouse's Other Name(s) (including Name at Birth)

Social Security Number

(c) Parent 1's Other Name(s) (including Name at Birth)

Social Security Number

(d) Parent 2's Other Name(s) (including Name at Birth)

Social Security Number

7.
10. Your Place of Birth (City and State or Foreign Country)

11. Spouse's Place of Birth (City and State or Foreign Country)
8.

9.
12. If you are filing for yourself, go to (a); if you are filing for a child, go to (e).

You
(a) Are you unable to work or is your work limited
because of illnesses, injuries, or conditions?

YES

Your Spouse, if filing
NO

YES

Go to #10
#13

Go to (b)

NO
#10
Go to #13

Go to (b)

(MM/DD/YYYY)

(MM/DD/YYYY)

(b) Enter the date you became unable to work
Go to (c)
(c) Are you blind or do you have low vision even with
glasses or contacts?

YES

NO

Go to (c)
YES

NO

Go to (d)

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

Go to (d)

YES

NO

Provide name(s) and Social
Security Number(s) in Remarks
#10
Go to #13

Go to #13

(e) When did the child become disabled? (MM/DD/YYYY)

Go to (f)

(f) Is the child blind or does he or she have low vision even with
glasses or contacts?
(g) Does the child have a parent or stepparent who is 62 or older,
unable to work because of illnesses, injuries, or conditions, or
deceased?

YES

NO

Go to (g)

Go to (g)

YES

NO

Provide name(s) and Social
Security Number(s) in Remarks
Go to #13

Go to #13

10.
13. If you (and your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a).

You
(a) Are you a naturalized United States citizen?

YES
Go to #17

(b) Are you an American Indian born outside the
United States?

YES
Go to (c)

Your Spouse, if filing
NO

Go to (b)
NO
Go to (d)

YES
Go to #17
YES
Go to (c)

NO
Go to (b)
NO
Go to (d)

Form SSA-8001-BK (09-2019) UF

Page 3 of 12

10.
13. (c) Check the block that shows your American Indian status.

You
American Indian born in Canada

Your Spouse, if filing
#14
Go to #17

Member of a Federally recognized Indian Tribe;
Name of Tribe:

American Indian born in Canada

#14
Go to #17

Member of a Federally recognized Indian Tribe;
Go to #17
#14

Other American Indian

Name of Tribe:

#14
Go to #17

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

Explain in Remarks, then Go to (d)

(d) Check the block below that shows your current immigration status.
You
Amerasian Immigrant

Your Spouse, if filing
#11
Go to #14

Asylee

Amerasian Immigrant

#11
Go to #14

Asylee

Date status granted (MM/DD/YYYY):

Date status granted (MM/DD/YYYY):
#13
Go to #16

Conditional Entrant

Go to #13
#16
Conditional Entrant

Date status granted (MM/DD/YYYY):

Date status granted (MM/DD/YYYY):
Go to #13
#16

#13
Go to #16

Cuban/Haitian Entrant

Go to #16
#13

Deportation/Removal Withheld

Cuban/Haitian Entrant

#13
Go to #16

Deportation/Removal Withheld

Date (MM/DD/YYYY):

Date (MM/DD/YYYY):
Go to #13
#16

#13
Go to #16

Lawful Permanent Resident
Parolee for One Year

Go to #14
#13
#13
Go to #16

Refugee

Lawful Permanent Resident
Parolee for One Year

Go to #13
#14
#13
Go to #16

Refugee

Date of entry (MM/DD/YYYY):

Date of entry (MM/DD/YYYY):
#13
Go to #16

Unknown/Other

Go to#13
#16
Unknown/Other

Explain in Remarks, then Go to (e)

Explain in Remarks, then Go to (e)

(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United States citizen, or a
lawfully admitted permanent resident, Go to #15; otherwise, Go to #17.

Form SSA-8001-BK (09-2019) UF

Page 4 of 12
You

Your Spouse, if filing

(MM/DD/YYYY)

(MM/DD/YYYY)

11.
14. (a) Date of admission:

(b) Was your entry into the United States sponsored
YES
by any person or promoted by an institution or
Go to (c)
group?

NO
Go to (d)

YES

NO

Go to (c)

Go to (d)

(c) Give the following information about the person, institution or group:
Name

Address

Phone Number

You

Your Spouse, if filing

(MM/DD/YYYY)

(MM/DD/YYYY)

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

From:
To:

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

NO
Go to #16

YES

NO

Go to (f)

Go to #16

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

Social Security Number

Name

Social Security Number
You

15.
12 (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?
13.
16. Are you, your spouse, or parent an active duty

member or a veteran of the armed forces of the
United States?

YES

Your Spouse, if filing
NO
#14
Go to #17

Go to (b)

YES

NO

Go to #16

#14
Go to #17

YES

NO

Explain in
Remarks, then
#14
Go to #17

#14
Go to #17

YES
Go to (b)

#14
Go to #17

YES

NO

Go to #16

#14
Go to #17

YES

NO

Explain in
Remarks, then
Go to #17
#14

Go to #14
#17

(MM/DD/YYYY)

(MM/DD/YYYY)

14.
17. (a) When did you first make your home in the United

NO

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

YES
Go to (c)

NO
#15
Go to #18

YES
Go to (c)

(MM/DD/YYYY)
Date
(c) Give the date(s) of residence outside the United Left:
States.
Date
Returned:

NO
#15
Go to #18
(MM/DD/YYYY)

Date
Left:
(MM/DD/YYYY)

(MM/DD/YYYY)
Date
Returned:

Form SSA-8001-BK (09-2019) UF

Page 5 of 12
You

18. (a) Have you been outside the United States (the 50
15.

YES

States, District of Columbia and Northern
Mariana Islands) 30 days prior to the filing date?

Your Spouse, if filing
NO

Go to (b)

YES

Go to #19
#16

(b) Give the date (MM/DD/YYYY) you left the
United States and the date you returned to the
United States.

(MM/DD/YYYY)
Date
Left:

ZIP Code

State/Province/Region (Foreign)

(MM/DD/YYYY)

(MM/DD/YYYY)

Date
Returned:
16.Claimant's Mailing Address (Number & Street, Apt. No., P.O. Box, or Rural Route)
19.

City and State (U.S.)

#16
Go to #19

Go to (b)

(MM/DD/YYYY)
Date
Left:

NO

Date
Returned:

Name of County in which you live
Postal Code

Telephone Number

Country

17.
20. If you are blind or visually impaired, check the type of mail you want to receive from us

Standard notice First-Class

Standard notice First-Class with a follow-up phone call

Standard notice & data CD by First-Class

Standard notice Certified

Standard & Braille notices by First-Class

Standard & large print notices

Standard notice & audio CD
You
18.
21. (a) Do you have any felony warrants for escape

from custody, flight to avoid prosecution or
confinement, or flight escape?
(b) In which State or country was the warrant
issued?

(c) Was the warrant satisfied?

YES

Your Spouse, if filing
NO

Go to (b)

YES

#19
Go to #22

Name of State/Country

NO

Go to (b)

Go to #22
#19

Name of State/Country

Go to (c)
YES

NO

Go to (d)

Go to #22
#19
(MM/DD/YYYY)

Go to (c)
YES

NO

Go to (d)

#19
Go to #22

(MM/DD/YYYY)

(d) Date warrant satisfied:
PART 2 - LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first moment of the filing date
month and today.)
19.
22. Claimant's Residence Address (Number & Street, Apt. No., P.O. Box, or Rural Route)

City and State (U.S.)

ZIP Code

Name of County in which you live

State/Province/Region (Foreign)

Postal Code

Country

Form SSA-8001-BK (09-2019) UF
20.
23. (a) Mark the box that describes where you live.

Page 6 of 12

House, apartment, mobile home, houseboat

Noninstitution (rest home, retirement home, foster home, or
group home)

Room in commercial establishment

Institution (hospital, rehabilitation center, prison, or school)

Room in private home

Transient or homeless

(b) Date you began living there: (MM/DD/YYYY)
21.
24. Mark the box that describes with whom you live. If you live in a foster home, group home, or an institution, or if you are a

transient or homeless, do not answer but explain in remarks.
Alone

Spouse/Parents and/or Children

Other People

PART 3 - RESOURCES (Show resources as of the first moment of the filing date month. Use "Remarks" to explain any
changes.)
22.
25. If you own, or your name or your spouse's/parent's name(s) appear on any of the following items (either alone or with other
people's name(s)), enter the total cash value of item(s) on each line.
Yes No

Description of Items
Marked Yes

Co-owned
With Others
Yes
No

Dollar Value
Spouse or
Parents Own

Dollar Value
You Own

(a) Trust.

$

$

(b) Vehicle.

$

$

(c) Real Property Other Than
Home.

$

$

(d) Business Equipment.

$

$

(e) Achieving a Better Life
Experience (ABLE) Account.

$

$

(f) Financial Institution Account.

$

$

(g) Cash.

$

$

(h) Stock, Bond or Mutual Fund.

$

$

(i) Promissory Note, Loan, or
Property Agreement.

$

$

(j) Items Held for Potential Value
or Investment.

$

$

(k) Life Insurance.

$

$

(l) Burial Fund.

$

$

(m) Burial Space or Related Item.

$

$

(n) Other Resource.

$

$

Your answer
23.
26. Are there any assets set aside to meet burial

Spouse's answer
expenses for you or your spouse/parent(s)? (If"Yes"
Parent 1's answer
describe the item in "Remarks".
Parent 2's answer

YES

NO

YES

NO

YES

NO

YES

NO

Form SSA-8001-BK (09-2019) UF

Page 7 of 12
Your Spouse, if filing

You
27. (a) Have you or your spouse sold, transferred title,
24.
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 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?

YES

NO

YES

NO

YES

NO

YES

NO

#25
IF YOU ANSWERED "YES" TO (a) or (b), GO TO (c). IF "NO" TO BOTH, GO TO #28.

(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

$
Sale Price or Other Consideration

Are Other Considerations or Proceeds
Expected? Explain

Do You Still Own Part
of the Property?

Item #1

YES

NO

Item #2

YES

NO

Item #3

YES

NO

Sold on Open Market?

Traded for Goods/
Services?

Given Away?

Item #1

YES

NO

YES

NO

YES

NO

Item #2

YES

NO

YES

NO

YES

NO

Item #3

YES

NO

YES

NO

YES

NO

You
25.
28. Do you give us permission to obtain any financial

records from any financial institution?

YES

Your Spouse, if filing
NO

YES

NO

PART 4 - INCOME (List all income received since the first moment of the filing date month or expected in the next 3
months.) Include you, your spouse/parents.

Form SSA-8001-BK (09-2019) UF
Page 8 of 12
26.
29. List cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect to receive. Include
income from wages, sick pay, self-employment, interest, social security, assistance based on need, VA, gifts, pensions, and
any other type of income. Give date last paid if income will stop in the next 3 months.
Person Receiving Income

Type of Income

Frequency
Received

Amount

Date Last Paid

Source of Income

$
$
$
Also, note here if anyone pays any bills for you directly or gives you money to pay them.
27.
30. (a) Does your spouse/parent pay court ordered child support?

YES

NO

Go to (b)

28.
Go to #31

(b) Give the amount and frequency of payment:
$
PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/
MEDICAL ASSISTANCE
Your Spouse, if filing

You
28.
31. (a) Are you currently receiving SNAP benefits

(formerly food stamps)?

YES

Go to (c)

YES

(b) Have you received a recertification notice within
the past 30 days?

Go to (e)

(c) Have you filed for SNAP benefits in the last 60
days?

Go to (d)

(d) Have you received a favorable decision?

NO

Go to (b)

NO
#29
Go to #32

YES

NO
Go to (e)

YES

NO

#29
Go to #32

(e) May I take your SNAP application today?

Go to (e)

YES

NO

#29
Go to #32

Explain in (f)

YES
Go to (b)
YES
Go to (e)
YES
Go to (d)
YES
#29
Go to #32

YES
#29
Go to #32

NO
Go to (c)
NO
Go to #29
#32
NO
Go to (e)
NO
Go to (e)
NO
Explain in (f)

(f) Explanation:

32. You may be eligible for Medicaid. However, you must help your State identify other sources that pay for medical care. Also,
29.
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 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)
Your Spouse, if filing

You
(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?

YES
Go to (b)

NO
Go to #33

YES
Go to (b)

NO
Go to #33

Form SSA-8001-BK (09-2019) UF

Page 9 of 12
Your Spouse, if filing

You
29.
32. (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.)
(c) Do you have any unpaid medical expenses for
the 3 months prior to the filing date month?

YES
Go to (c)
YES
#30

Go to #33

NO
Go to (c)

YES
Go to (c)

NO
#30
Go to #33

NO
Go to (c)

YES
Go to #30
#33

NO
#30
Go to #33

PART 6 - MISCELLANEOUS
ANSWER #33(a) ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE;
OTHERWISE GO TO #33(b).
30.
33. (a) Name of Person Requesting Benefits

(b) Have you ever served as representative payee for a Social
Security beneficiary or SSI claimant?

Relationship to Claimant

YES
Go to #34

Your Social Security Number

NO
Go to #34

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.)

Form SSA-8001-BK (09-2019) UF

Page 10 of 12

PART 8 - IMPORTANT INFORMATION - PLEASE READ CAREFULLY
34. 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.
PART 9 - SIGNATURES
35. 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.
36. Your Signature (First name, middle initial, last name) (Write in ink.)

Date (MM/DD/YYYY)

37. Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)

WITNESSES
38. 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

2. Signature of Witness

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

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

Form SSA-8001-BK (09-2019) UF

Page 11 of 12

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 write to:

Your application for Supplemental Security Income will be processed as quickly as possible. You should hear from us within
days. If you do not hear from us within that time, please get in touch with us in person, by mail, or call us at the telephone number
shown at the top of this page.
We may need more information before we can decide whether or not you are eligible for SSI payments. If we need more
information, we will contact you. In the meantime, if you move or change your mailing address, you (or someone for you) should
report the change to the office shown at the top of this page.
You (or someone for you) must let us know if your immigration status changes.
Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. You could lose some
SSI payments if you do not let us know right away.
Always give your Social Security Number when writing or telephoning about your claim. If you have any questions about your
claim, we will be glad to help you.

Form SSA-8001-BK (09-2019) UF

Page 12 of 12
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 this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any
claim filed.
We will use the information to determine eligibility for Supplemental Security Income (SSI) payments. We may also
share your information for the following purposes, called routine uses:
• To specified business and other community members and Federal, State, and local agencies for verification of
eligibility for benefits under section 1631(e) of the Act; 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 Systems, as published in the Federal Register (FR) on April 01, 2003, at 68FR 15784, 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 19-20 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.