Form SSA-8203-BK at a glance
What it is: Form SSA-8203-BK is a statement the Social Security Administration needs to determine if you continue to be eligible for supplemental security income (SSI) payments.
Who signs: Write in ink your signature: first name, middle initial, last name.
A filled-in Form SSA-8203-BK example: an SSI recipient who moved
How to fill out Form SSA-8203-BK, box by box
Marital status
Check Yes or No: since the date in the box "WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE", has your marital status (or the marital status of your parents if you are a child) changed?
Moved to a new address
Since the date in the box "WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE", have you moved to a new address? If "yes," give the new address: address (number, street, city, state, and ZIP code) and the date you moved.
Outside the United States
Since the date in the box "WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE", have you been outside the United States (the 50 States, District of Columbia, and Northern Mariana Islands)? If "yes," please give the date(s) left (month/day/year) and the date(s) returned (month/day/year).
Hospital, nursing home, or other institution
Since the date in the box "WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE", have you spent a full calendar month in a hospital, nursing home, or other institution? If "yes," please give the date entered (month/day/year), the date left (month/day/year), the name of the institution and the address (number, street, city, state and ZIP code).
Where you live and who moved in or out
Mark X in the box which best describes where you live: house, apartment, room, mobile home, nursing home, rest or retirement home, hospital, rehabilitation center, school, other (specify). Since the date in the box "WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE", has anyone moved into or out of the place where you live? (including births and deaths) If "yes," please give: name, relationship, age, blind or disabled, ineligible child, date moved in, date moved out.
Other people in your household
Do any other people live in the same household with you or your spouse? If "yes," please give the following information about them (including children):
Enter name, relationship, age and/or date of birth, blind or disabled, ineligible child, married, income, student.
Signing, with witnesses and a representative payee
Write in ink your signature: first name, middle initial, last name.
The spouse signs only if receiving SSI payments: write in ink the spouse's signature, with first name, middle initial, last name.
If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign and give their full names and addresses.
A representative payee writes in ink the full name, the title or relationship to the recipient, the address, the area code and telephone number where the payee can be reached, and the date.
More rules for Form SSA-8203-BK
I give my permission for the Social Security Administration to check the information I have given on this form, and to ask my employer(s) for information about my wages.
You can report changes by calling toll free at 1-800-772-1213.
If your situation is different
You or your spouse worked or expect to work
Since the date on page 1, have you, or your spouse living with you, worked OR do you expect to work in the next 14 months?
You or your spouse were self-employed
Since the date on page 1, have you, or your spouse living with you, been self-employed or expect to be self-employed in the current taxable year?
You or your spouse received income
Since the date on page 1, have you, or your spouse living with you, received, or do you expect to receive in the next 14 months, any of the income listed below? If the answer is "yes," to any of these types of unearned income, please give.
You or your spouse own items
Do you, or your spouse living with you, own any of the following items (answer "yes" if your name appears alone or with any other person as the owner or part owner of any of these items):
Cash (with you, at home, in a safe deposit box); checking accounts; savings accounts; credit union accounts; Christmas club accounts; savings certificates/certificates of deposit; promissory notes or IOU's; stocks or bonds; other items that can be cashed or sold.
You live in California
If you live in California, please do not answer question 24.
The address where you live is different than the address where you get your mail
If the address where you live is different than the address where you get your mail, please give the address where you live.
Common questions about Form SSA-8203-BK
Is there a deadline?
You must report certain changes that happen to you within 10 days after the month they happen.
Where do I file it?
Send 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.
Is there a penalty?
I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
What am I certifying when I sign?
By signing 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-8203-BK (5-2003), Statement for Determining Continuing Eligibility for Supplemental Security Income Payments, Social Security Administration (the served file; no issuer file found) (the Official source link on this page).