SSA-8006-F4 Statement of Living Arrangements, In Kind Support and Ma

Form Approved
OMB No. 0960-0174

SOCIAL SECURITY ADMINISTRATION

STATEMENT OF LIVING ARRANGEMENTS, IN-KIND SUPPORT AND MAINTENANCE
Claimant's/Recipient's Name (Print, first, middle initial, last)

Claimant's/Recipient's Social Security
Number

Claimant's/Recipient's Spouse's Name (Print if spouse applying or
receiving benefits)

Spouse's Social Security Number

Date of Change of Living Situation (If applicable)

Type of Change (Change of residence, household composition,
contribution amount, etc.)

This SSA-8006-F4 Covers the Period Beginning

Through

PART 1
Initial Claims: Complete Part 1 when a change in living arrangement occurs after claim is filed and claim is pending.
Posteligibility: Complete Part 1 when response(s) to questions on the SSA-8202 (short form Statement for Determining
Continuing Eligibility for Supplemental Security Income Payments) require additional living arrangement development.
1. CHECK THE BLOCKS WHICH BEST DESCRIBE YOUR LIVING ARRANGEMENTS
A. I live (with):
Alone

Eligible spouse

Ineligible spouse

Parent(s)

Child(ren)

Essential person

Other people

Sponsor

House

Apartment

Room (Commercial establishment)

Room (private home)

Mobile home

Other (specify)

B. I live in a:

C. Total number of people in household (including yourself)
2.

Check "YES" or "NO" to the following questions and provide additional information as requested.
A. Do you (and/or your spouse, or deemor) own or are you (and/or your
spouse, or deemor) buying the home you live in? If "yes", go to
question 3.

YES

NO

B. Do you (and/or your spouse, or deemor) rent the place where you
live? If "yes," go to D.

YES

NO

C. Does anyone who lives with you rent the place where you live?
If "no," go to question 3.

YES

NO

D. Are you or anyone you live with related to the landlord
(landlord's spouse)?

YES

NO

If "yes", indicate relationship
E. If you answered "yes" to B. or C., provide the following information:
Landlord's Address

Landlord's Name

Landlord's Phone Number

Form SSA-8006-F4 (06-2014) EF (06-2014)
Destroy Prior Editions

Date Rental Agreement Began
month
year
Page 1

Monthly Rental Amount

$

3. Does any Agency, Organization or anyone who does not live with you pay, or
help you pay for any of the following items: Food, Rent, Home Mortgage
Payments, Property Insurance (if required by Mortgage Holder), Real
Property Taxes, Heating Fuel, Gas, Electricity, Garbage Removal, Water and/
or Sewer Bills?

YES

NO

If "yes," please provide the following information about each item you receive, then go to question 4.
Item

4.

Name, Address, and Telephone Number of Contributor
Name
Telephone Number
Address

Frequency
In Cash In-Kind
of Payment

If you do not live with others, skip to Part 3. If you live with others, do all the
other household members receive some type of public payment based on
need (e.g., TANF, BIA, SSI, VA)?

YES

Dollar
Value

NO

Agency Name

IF "Yes," indicate from which agency, then go to Part 3.
IF "No," go to Part 2.

PART 2
Complete Part 2 when individual lives with at least one person other than, or in addition to, spouse, child(ren), or person
whose income may be deemed to the individual.
1. Check "YES" or "NO" to the following questions or provide the information requested.
A. Do you eat all your meals out?
If "Yes," go to C.
If "No," go to B.
B. Do you buy all your food separately from other household members?
C. How much is your average cash contribution per month toward the
household expenses listed in 4 below.

3.

If you or your spouse own or rent, show the total monthly cash contributions
from others with whom you live:

NO

YES

NO

YES

NO

$

D. Do you have an agreement to pay back the people you live with for
your share of the household expenses?
2.

YES

$

Check "YES" or "NO" to the following questions and provide additional information as requested only if you answered
"NO" to both questions 1.A. and 1.B. and you do not own or rent the place where you live.
YES

A. Is part or all of the amount in question 1.C. just
for food?

NO

How Much?

$

YES

B. Is part or all of the amount in question 1.C. just
for shelter?

How Much?

$

Form SSA-8006-F4 (06-2014) EF (06-2014)

Page 2

NO

4.

WHAT IS THE AVERAGE MONTHLY AMOUNT OF THE FOLLOWING HOUSEHOLD CASH EXPENSES FOR THE
PERIODS INDICATED?
FROM

THROUGH FROM

THROUGH FROM

THROUGH

CASH EXPENSES

Food (Complete only if both 1.A. and 1.B.
above are answered "no")

$ 0.00

$ 0.00

$ 0.00

Mortgage or rent

$ 0.00

$ 0.00

$ 0.00

Property insurance (if required by mortgage
holder)

$ 0.00

$ 0.00

$ 0.00

Real property taxes

$ 0.00

$ 0.00

$ 0.00

Heating fuel

$ 0.00

$ 0.00

$ 0.00

Electricity

$ 0.00

$ 0.00

$ 0.00

Gas

$ 0.00

$ 0.00

$ 0.00

Water

$ 0.00

$ 0.00

$ 0.00

Sewer

$ 0.00

$ 0.00

$ 0.00

Garbage removal

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

$ 0.00

Total

REMARKS: You may use this space for any explanations. Enter the item number before each explanation. If you
need more space, use a signed SSA-795.

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 7 minutes to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is 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
See Revised Paperwork Reduction
this address, not the completed form.
Form SSA-8006-F4 (06-2014) EF (06-2014)

Act
Statement
Page 3

PART 3
YOUR RESPONSIBILITIES: Anyone who knowingly and willfully makes or causes to be made a false statement or
representation of material fact in an application or for use in determining a right to payment under the Social Security Act
commits a crime punishable under Federal or State law or both.
Do you understand that the information provided is subject to verification and do
YES
NO
you authorize sources to release to the Social Security Administration information
needed to verify your statements?
Do you understand that if there is any change in the information you have
provided on this statement that you must report it to the Social Security
YES
NO
Administration because your eligibility or benefit amount could be affected?
Do you understand that failure to report any change could result in a penalty to
you of $25 to $100 if the report is not made within 10 days after the end of the
YES
NO
month in which the change occurred?
Do you affirm that all the information you gave in this document or in support of it
YES
NO
is true?
Privacy Act Notice
Collection and Use of Personal Information
See Revised
Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the
Privacy
Act
information you provide to determine your living arrangements. Furnishing us this information
is voluntary.
However, failing
to provide us with all or part of the information could prevent us from making an accurate
and
timely
decision
on your claim,
Statement
and could result in the loss of some payments.
We rarely use the information you supply for any purpose other than for determining your living arrangements. 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
Social Security 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 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, audit, or investigative activities necessary to assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
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 list of routine uses for this information are available in Systems of Records Notices entitled, Master Beneficiary
Record, 60-0090, and Supplemental Security Income Record, 60-0103. These notices, additional information regarding this
form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your local
Social Security office.
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.

SIGNATURES
Your Signature (First Name, Middle Initial, Last Name)(Write in Ink)

Date (Month, Day, Year)

Spouse's Signature (First Name, Middle Initial, Last Name)(Write in Ink)

Telephone Number(s) at Which You
May Be Contacted During the Day
(Include Area Code)

Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)
City and State

ZIP Code

Enter Name of County (if any)

NOTE: If residence address is different from mailing address, show in "Remarks".
This statement 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-8006-F4 (06-2014) EF (06-2014)

Page 4