Form SSA-8000-BK at a glance
What it is: Form SSA-8000-BK (09-2024) is the Application for Supplemental Security Income (SSI).
Who signs: Your Signature (First name, middle initial, last name) (Sign in ink.) and the Date (MM/DD/YYYY). Spouse's Signature (Sign only if applying for payments.) (First name, middle initial, last name) (Sign in ink.)
Where and when to file: 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.
Social Security Administration staff or others who help people apply for SSI will fill out this form for you.
You 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.
A filled-in Form SSA-8000-BK example: an individual applies for SSI
How to fill out Form SSA-8000-BK, box by box
Type of claim
TYPE OF CLAIM Individual, Individual with Ineligible Spouse, Couple, Child or Child with Parents. PART 1 BASIC ELIGIBILITY: Answer the questions below beginning with the first moment of the filing date month.
1. (a) First Name, Middle Initial, Last Name
1. (a) First Name, Middle Initial, Last Name, Birthdate (MM/DD/YYYY) and Social Security Number; Sex Male or Female.
(b) Other names or Social Security Numbers
(b) Did you ever use any other names (including maiden name) or any other Social Security Numbers? YES Go to (c). NO Go to (d). (c) Other Name(s) and Other Social Security Number(s) used.
(d) Parent 1's Name(s) and Parent 2's Name(s)
(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:
Parent 1's Name(s). Parent 2's Name(s). Parent 1's Other Name(s) (Including Name at Birth). Parent 2's Other Name(s) (Including Name at Birth).
Mailing Address and Residence Address
2. Applicant's Mailing Address (Number & Street, Apt. No., P.O. Box, Rural Route), City and State (U.S.)/State/Province/Region (Foreign), ZIP Code/Postal Code, County/Country.
3. Claimant's Residence Address (If different from applicant's mailing address), City and State (U.S.)/State/Province/Region (Foreign), ZIP Code/Postal Code, County/Country.
4. DIRECT DEPOSIT PAYMENT INFORMATION
4. DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION): Routing Transit Number and Account Number; Checking or Savings; Enroll in Direct Express; Direct Deposit Refused.
If your situation is different
You are married
5. (a) Are you married? YES Go to (b). NO Go to #6.
(f) Are you and your spouse living together? YES Go to #6. NO Go to (g).
You are filing for a child
If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
(e) When did the child become disabled? (MM/DD/YYYY)
You are applying on behalf of someone else
PART 6 MISCELLANEOUS: Answer #60 ONLY IF YOU ARE APPLYING ON BEHALF OF SOMEONE ELSE: OTHERWISE GO TO #61.
You need more space for explanations
In 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.
You signed by mark (X)
64. WITNESS: 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 giving their full address.
The questions in PART 2 and PART 3
PART 2 LIVING ARRANGEMENTS: The questions in this section refer to the signature date.
PART 3 RESOURCES: The questions in this section pertain to the first moment of the filing date month.
Common questions about Form SSA-8000-BK
Who signs it?
Your Signature (First name, middle initial, last name) (Sign in ink.) and the Date (MM/DD/YYYY).
Where do I file it?
Send or bring the completed form to your local Social Security office.
Is there a penalty?
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.
What am I certifying when I sign?
You declare under penalty of perjury that you 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 your knowledge.
Sources
[1] Form SSA-8000-BK (09-2024), Application for Supplemental Security Income (SSI), Social Security Administration (the Official source link on this page).