Form Ssa 8001 Bk PDF Details

Form SSA 8001 Bk is a report of earnings used by the Social Security Administration to determine an individual's benefits. This form must be completed by both the employer and the employee, and submitted to the SSA each year. The information on this form is used to calculate benefits for retirees, disabled workers, and their families. The deadline for submitting Form SSA 8001 Bk is January 31st each year. Make sure you submit your report on time so that you receive the correct benefit payments!

QuestionAnswer
Form NameForm Ssa 8001 Bk
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesssa 8001 bk 2021, ssa 8001, form ssa 8001 bk 09 2019, ssa 8001 form

Form Preview Example

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

 

 

 

Discontinue Prior Editions

 

 

Page 1 of 12

Social Security Administration

OMB

No. 0960-0444

 

 

 

 

 

 

Do Not Write in This Space

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)

 

 

 

(Deferred or Abbreviated)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEFERRED

 

ABAP

 

 

 

 

 

 

 

SNAP-

 

SNAP-

I am/We are applying for Supplemental Security Income and any federally

SSA/APP

 

REFERRED

Filing Date (MM/DD/YYYY)

administered state supplementation under Title XVI of the Social Security

 

 

 

Act, for benefits under the other programs administered by the Social

 

 

Receipt

Protective

Security Administration, and where applicable, for medical assistance under

 

Preferred Language:

Title XIX of the Social Security Act.

 

 

 

 

 

 

 

 

 

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

2. Sex

3. Birthdate

4. Social Security Number

 

Male

(MM/DD/YYYY)

 

 

Female

 

 

 

 

 

 

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

6(a). Sex

7(a). Birthdate

8 (a). Social Security Number(s)

 

Male

(MM/DD/YYYY)

 

 

Female

 

 

 

 

 

 

If filing for child (b) Parent 1's Name(s)

6(b). Sex

7(b). Birthdate

8 (b). Social Security Number(s)

 

Male

(MM/DD/YYYY)

 

 

Female

 

 

 

 

 

 

If filing for child (c) Parent 2's Name(s)

6(c). Sex

7(c). Birthdate

8 (c). Social Security Number(s)

 

Male

(MM/DD/YYYY)

 

 

Female

 

 

 

 

 

 

8(d). Are you married?

YES, complete (e) and (f)

NO, Go to (g)

(e)Date of Marriage (MM/DD/YYYY)

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

YES

NO If no, date you began living apart

(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)

. Go to (h)*.

NO Go to #9.

*(h) Other person's name (First, middle initial, last)

Other person's Social Security Number

*Use SSA-4178 to develop the holding out relationship.

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

Page 2 of 12

 

 

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

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

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

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

 

 

You

Your Spouse, if filing

(a) Are you unable to work or is your work limited

 

 

 

 

YES

NO

YES

NO

because of illnesses, injuries, or conditions?

Go to (b)

Go to #13

Go to (b)

Go to #13

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

(MM/DD/YYYY)

(b) Enter the date you became unable to work

 

 

 

 

 

 

Go to (c)

 

Go to (c)

 

 

 

 

 

(c) Are you blind or do you have low vision even with

YES

NO

YES

NO

glasses or contacts?

 

Go to (d)

 

Go to (d)

 

 

 

 

 

 

 

 

(d) If you were unable to work because of illnesses, injuries, or

YES

 

NO

conditions before age 22, do you have a parent or stepparent

Provide name(s) and Social

Go to #13

who is age 62 or older, unable to work because of illnesses,

Security Number(s) in Remarks

injuries, or conditions, or deceased?

 

 

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

YES

 

NO

glasses or contacts?

 

Go to (g)

 

Go to (g)

 

 

 

 

 

YES

 

NO

(g) Does the child have a parent or stepparent who is 62 or older,

 

Provide name(s) and Social

Go to #13

unable to work because of illnesses, injuries, or conditions, or

Security Number(s) in Remarks

deceased?

 

 

Go to #13

 

 

 

 

 

 

 

 

 

 

 

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

 

 

You

Your Spouse, if filing

 

 

 

 

 

(a) Are you a naturalized United States citizen?

YES

NO

YES

NO

 

 

 

 

 

Go to #17

Go to (b)

Go to #17

Go to (b)

 

 

 

 

 

(b) Are you an American Indian born outside the

YES

NO

YES

NO

United States?

Go to (c)

Go to (d)

Go to (c)

Go to (d)

 

 

 

 

 

 

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

 

 

Page 3 of 12

 

 

 

 

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

 

 

 

 

 

 

 

 

You

 

Your Spouse, if filing

 

 

 

 

 

 

 

American Indian born in Canada

Go to #17

American Indian born in Canada

Go to #17

 

 

 

 

 

 

 

 

Member of a Federally recognized Indian Tribe;

 

Member of a Federally recognized Indian Tribe;

 

Name of Tribe:

Go to #17

Name of Tribe:

Go to #17

 

 

 

 

 

 

 

 

 

Other American Indian

 

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

 

Your Spouse, if filing

 

 

 

 

 

 

 

Amerasian Immigrant

Go to #14

Amerasian Immigrant

Go to #14

 

 

 

 

 

 

 

 

 

Asylee

 

Asylee

 

 

Date status granted (MM/DD/YYYY):

 

Date status granted (MM/DD/YYYY):

 

 

 

Go to #16

 

Go to #16

 

 

 

 

 

 

Conditional Entrant

 

Conditional Entrant

 

 

Date status granted (MM/DD/YYYY):

 

Date status granted (MM/DD/YYYY):

 

 

 

Go to #16

 

Go to #16

 

 

 

 

 

 

Cuban/Haitian Entrant

Go to #16

Cuban/Haitian Entrant

Go to #16

 

 

 

 

 

 

 

 

 

Deportation/Removal Withheld

 

Deportation/Removal Withheld

 

 

Date (MM/DD/YYYY):

 

Date (MM/DD/YYYY):

 

 

 

Go to #16

 

Go to #16

 

 

 

 

 

 

Lawful Permanent Resident

Go to #14

Lawful Permanent Resident

Go to #14

 

 

 

 

 

 

 

 

 

Parolee for One Year

Go to #16

Parolee for One Year

Go to #16

 

 

 

 

 

 

 

 

 

Refugee

 

Refugee

 

 

Date of entry (MM/DD/YYYY):

 

Date of entry (MM/DD/YYYY):

 

 

 

Go to #16

 

Go to #16

 

 

 

 

 

 

Unknown/Other

 

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)

14. (a) Date of admission:

 

 

 

 

 

 

 

 

 

 

 

(b) Was your entry into the United States sponsored

YES

NO

YES

NO

 

by any person or promoted by an institution or

 

Go to (c)

Go to (d)

Go to (c)

Go to (d)

 

group?

 

 

 

 

 

 

 

 

 

 

 

(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:

 

From:

 

 

adjustment to lawful permanent resident?

 

 

 

 

To:

 

To:

 

 

 

 

 

 

 

 

 

 

 

(e) If filing as an adult, did your parents ever work in

YES

NO

YES

NO

 

the United States before you were 18?

Go to (f)

Go to #16

Go to (f)

Go to #16

 

 

 

 

 

 

 

 

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

Name

Name

Social Security Number

Social Security Number

 

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

 

 

 

15. (a) Have you, your child, or your parent, been

YES

NO

YES

NO

 

subjected to battery or extreme cruelty while in

 

Go to (b)

Go to #17

Go to (b)

Go to #17

 

the United States?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Have you, your child, or your parent filed a

 

 

 

 

 

 

 

petition with the Department of Homeland

YES

NO

YES

NO

 

Security for a change in immigration status

 

Go to #16

Go to #17

Go to #16

Go to #17

 

because of being subjected to battery or

 

 

 

 

 

 

 

 

extreme cruelty?

 

 

 

 

 

 

 

 

YES

NO

YES

NO

16. Are you, your spouse, or parent an active duty

Explain in

Go to #17

Explain in

Go to #17

 

member or a veteran of the armed forces of the

 

Remarks, then

Remarks, then

 

United States?

 

Go to #17

 

Go to #17

 

 

 

 

 

 

 

 

 

 

 

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

(MM/DD/YYYY)

(MM/DD/YYYY)

 

 

 

 

 

 

 

States?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b) Have you lived outside of the United States

YES

NO

YES

NO

 

since then?

Go to (c)

Go to #18

Go to (c)

Go to #18

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

 

(MM/DD/YYYY)

 

 

Date

 

 

Date

 

 

 

(c) Give the date(s) of residence outside the United

Left:

 

 

Left:

 

 

 

States.

 

 

(MM/DD/YYYY)

 

 

(MM/DD/YYYY)

 

 

Date

 

 

Date

 

 

 

 

Returned:

 

 

Returned:

 

 

 

 

 

 

 

 

 

 

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

 

 

 

Page 5 of 12

 

 

 

 

 

 

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

 

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

YES

NO

YES

NO

 

States, District of Columbia and Northern

 

Go to (b)

Go to #19

Go to (b)

Go to #19

 

Mariana Islands) 30 days prior to the filing date?

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

(MM/DD/YYYY)

 

(b) Give the date (MM/DD/YYYY) you left the

Date

 

Date

 

 

Left:

 

Left:

 

 

United States and the date you returned to the

 

 

 

(MM/DD/YYYY)

 

(MM/DD/YYYY)

 

United States.

 

 

 

 

 

 

 

 

 

Date

 

Date

 

 

 

Returned:

 

Returned:

 

 

 

 

 

 

 

19. Claimant's Mailing 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

Telephone Number

State/Province/Region (Foreign)

Postal Code

Country

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

 

Your Spouse, if filing

 

 

 

 

 

 

 

21. (a) Do you have any felony warrants for escape

YES

NO

 

YES

NO

 

from custody, flight to avoid prosecution or

 

 

 

 

 

 

 

 

confinement, or flight escape?

Go to (b)

Go to #22

 

Go to (b)

Go to #22

 

 

 

 

 

 

(b) In which State or country was the warrant

Name of State/Country

 

Name of State/Country

 

 

 

 

 

 

 

issued?

 

Go to (c)

 

 

Go to (c)

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) Was the warrant satisfied?

YES

NO

 

YES

NO

 

Go to (d)

Go to #22

 

Go to (d)

Go to #22

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

 

(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.)

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

Page 6 of 12

 

 

23. (a) Mark the box that describes where you live.

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

 

House, apartment, mobile home, houseboat

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)

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.)

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.

 

 

 

 

Description of Items

Co-owned

 

Dollar Value

Dollar Value

 

 

Yes

No

With Others

 

Spouse or

 

 

Marked Yes

 

You Own

 

 

 

 

 

 

 

Parents Own

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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.

$

$

26.Are there any assets set aside to meet burial expenses for you or your spouse/parent(s)? (If"Yes" describe the item in "Remarks".

Your answer

YES

NO

 

 

 

Spouse's answer

YES

NO

 

 

 

Parent 1's answer

YES

NO

 

 

 

Parent 2's answer

YES

NO

 

 

 

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

 

 

 

Page 7 of 12

 

 

 

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

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

 

 

 

 

disposed of or given away, any money or other

 

 

 

 

property, including money or property in foreign

YES

NO

YES

NO

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

YES

NO

YES

NO

property within the 36 months prior to the filing

 

 

 

 

date month?

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Address of Purchaser or

 

Relationship to Owner

 

Value of Property and/

 

 

Recipient

 

 

 

 

or Amount of Cash Gift

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #1

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #2

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #3

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

Sale Price or Other Consideration

Are Other Considerations or Proceeds

Do You Still Own Part

 

 

 

Expected? Explain

 

of the Property?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #1

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #2

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #3

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

Sold on Open Market?

 

Given Away?

 

Traded for Goods/

 

 

 

 

Services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

Your Spouse, if filing

 

 

 

 

 

 

 

 

 

28. Do you give us permission to obtain any financial

 

YES

 

NO

 

YES

NO

records from any financial institution?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

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

Amount

Frequency

Received

Date Last Paid

Source of Income

$

$

$

Also, note here if anyone pays any bills for you directly or gives you money to pay them.

 

 

 

 

30. (a) Does your spouse/parent pay court ordered child support?

YES

NO

Go to (b)

Go to #31

 

 

 

 

 

 

(b)Give the amount and frequency of payment:

$

PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/ MEDICAL ASSISTANCE

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

 

31. (a) Are you currently receiving SNAP benefits

YES

NO

YES

NO

 

(formerly food stamps)?

Go to (b)

Go to (c)

Go to (b)

Go to (c)

 

 

 

 

 

 

 

(b) Have you received a recertification notice within

YES

NO

YES

NO

 

 

 

 

 

 

the past 30 days?

Go to (e)

Go to #32

Go to (e)

Go to #32

 

 

 

 

 

 

 

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

YES

NO

YES

NO

 

days?

Go to (d)

Go to (e)

Go to (d)

Go to (e)

 

 

 

 

 

 

 

 

 

(d) Have you received a favorable decision?

YES

NO

YES

NO

 

 

 

 

 

 

 

Go to #32

Go to (e)

Go to #32

Go to (e)

 

 

 

 

 

 

 

(e) May I take your SNAP application today?

YES

NO

YES

NO

 

 

 

 

 

 

 

Go to #32

Explain in (f)

Go to #32

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, 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)

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

 

 

(a) Do you agree to assign your rights (or the

 

 

 

 

 

rights of anyone for whom you can legally

YES

NO

YES

NO

 

assign rights) to payments for medical

 

Go to (b)

Go to #33

Go to (b)

Go to #33

 

support and other medical care to the State

 

 

 

 

 

 

Medicaid agency?

 

 

 

 

 

 

 

 

 

 

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

 

 

 

Page 9 of 12

 

 

 

 

 

 

You

Your Spouse, if filing

 

 

 

 

 

32. (b) Do you, your spouse, parent or stepparent have

 

 

 

 

any private, group, or governmental health

YES

NO

YES

NO

insurance that pays the cost of your medical

Go to (c)

Go to (c)

Go to (c)

Go to (c)

care? (Do not include Medicare or Medicaid.)

 

 

 

 

 

 

 

 

 

(c) Do you have any unpaid medical expenses for

YES

NO

YES

NO

the 3 months prior to the filing date month?

Go to #33

Go to #33

Go to #33

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).

33. (a) Name of Person Requesting Benefits

Relationship to Claimant

Your Social Security Number

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

YES

NO

Go to #34

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.

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