Ssa 8001 F5 Form PDF Details

The Social Security Administration's SSA-8001-F5 form stands at the forefront of initiating an application process for Supplemental Security Income (SSI), a program designed to aid individuals with little or no income and who are aged, blind, or disabled. This critical document not only serves as a gateway for potential benefit recipients seeking financial assistance but also encompasses applications for any federally administered state supplementation under Title XVI of the Social Security Act. Beyond SSI, the form seeks to establish eligibility for benefits under other programs administered by the Social Security Administration and, where applicable, for medical assistance under Title XIX of the Social Security Act. Prospective applicants are navigated through a series of sections, which collect comprehensive personal information, including name, social security number, living arrangements, resources, and income details. Furthermore, the form inquires about current receipt of food stamps and expresses interest in applying for the program if not already receiving benefits. The underlying emphasis on detailed personal and financial information underscores the form's role in ensuring applicants meet the stringent criteria set forth for eligibility, thereby serving as a linchpin in the administration of social welfare benefits.

QuestionAnswer
Form NameSsa 8001 F5 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesssa f5 form, ssa 8001 bk 2021, 8001 form, ssa 8001f5 security

Form Preview Example

 

 

 

□ TEL

 

 

 

 

 

 

 

FORM APPROVED

SOCIAL SECURITY ADMINISTRATION

 

 

 

 

 

 

 

OMB NO. 0960-0444

 

 

 

 

 

 

 

 

 

 

Do not write in this space.

 

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am/We are applying for Supplemental Security

 

 

 

 

 

 

 

Income and any federally administered State

 

 

 

 

 

 

 

supplementation under title XVI of the Social Security

 

 

 

 

 

 

 

 

 

DEFFERRED

 

 

ABAP

Act, for benefits under the

other

programs

 

 

 

 

 

 

FS-SSA APP

 

 

FS-REFERRED

administered by the Social Security Administration,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FILING DATE

and where applicable, for medical assistance under

 

 

 

 

Month, Day, Year

 

 

 

title XIX of the Social Security Act.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual

or

 

Protective

 

 

 

 

 

 

 

 

 

 

 

TYPE OF CLAIM

INDIVIDUAL WITH

COUPLE

INDIVIDUAL

 

 

CHILD

 

CHILD WITH PARENTS

INELIGIBLE SPOUSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I – BASIC ELIGIBILITY

 

 

 

 

 

 

 

 

 

 

 

 

1.

First Name, Middle Name, Last Name

 

2. Birth (month,

 

3. Sex

 

4. Social Security Number

 

 

 

 

 

day, year)

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

5.

Spouse (Parent(s)) Name(s)

 

6. Birth (month,

 

7. Sex

 

8. Social Security Number(s)

 

 

 

 

 

day, year)

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

9.Other Names and Social Security Numbers you, your spouse (parents) used.

 

a. Your Other Names (including Maiden Name)

 

Your Other Social Security Numbers

 

 

 

 

 

b. Spouse’s (Mother’s) Other Names (including Maiden Name)

Spouse’s (Mother’s) Other Social

 

 

 

Security Numbers

 

 

 

 

 

c. Father’s Other Names

 

Father’s Other Social Security

 

 

 

Numbers

 

 

 

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 or your spouse (parents) are blind or disabled, note the date the impairment began and type of impairment.

 

 

Date Impairment began

 

 

Type of impairment

 

 

 

Your Answer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s (Mother’s) Answer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s Answer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you (and your spouse applying for benefits) were United States citizens at birth, go to question 14.

 

 

13. a. Are you a naturalized United States citizen or lawfully

Your Answer

Spouse’s Answer, if filing

 

 

admitted for permanent residence in the United

YES

NO

YES

NO

 

States?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. If you are lawfully admitted for permanent residence,

DATE (month, day, year)

DATE (month, day, year)

 

 

 

 

 

 

 

give the month / day / year of lawful admission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If the individual or spouse applying for benefits is not a citizen or lawfully admitted for permanent residence, explain in “Remarks.”

Form SSA-8001-F5 (12-2002)

Page 1

PART II – LIVING ARRANGEMENTS TODAY –

(Use “Remarks” to explain any change between the first

moment of the filing date month and today.)

 

14.Mark the box that describes where you live. If more than one type of residence is next to the box, put a circle around the best description.

House, apartment, mobile home, room in

Room in a private home

a commercial establishment

Foster Home

School, rehabilitation center, rest, retirement or

Other (Specify) ____________________________

__________________________________________

nursing home, hospital, or jail

 

15.Mark the box that describes with whom you live. If you live in a foster home or an institution, or if you are a transient, do not answer but explain in “Remarks.”

Alone

Spouse / Parents and Children

Other People

 

 

PART III – RESOURCES –

(Show resources as of the first moment of the filing date month. Use “Remarks” to

explain any change since that time.)

 

 

 

16.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 names, circle the item(s) and enter the total cash value of item(s) circled on each line.

Description

Yes No

Dollar Value

Dollar Value Spouse

You Own

or Parents Own

 

 

a. Cash at home, with you, or anywhere else

 

 

 

 

b. Savings, checking accounts, stocks, bonds

 

 

 

 

c. Insurance policies

 

 

 

 

d. Vehicles (cars, trucks, boats, motorcycles). How many ____?

 

 

 

 

e. Property other than the home you live in

 

 

 

 

f. Life estates or property you inherited

 

 

 

 

g. Other items that can be turned into cash

 

 

 

 

17.

Your Answer

 

Yes

No

Are any items listed in question 16 set aside to meet burial

 

 

 

 

 

expenses for you or your spouse (parents)? (If “Yes”, describe

Spouse (Mother’s) Answer

Yes

No

the item in “Remarks.”)

Father’s Answer

Yes

No

 

PART IV – INCOME – (List all income received or expected to be received since the first moment of the filing date month.)

18.

List cash, checks, and direct payments to bank accounts you (your spouse / parents) received or expect to receive. Include income from wages, self-employment, interest, social security, assistance based on need, VA, gifts, pensions, and any other type of income. Note if current income will stop in the next 3 months. Also note here if anyone pays any bills for you directly or gives you money to pay them.

 

Person Receiving

Type of Income

Amount

Frequency

Source of Income

 

Income

Received

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

$

 

 

Form SSA-8001-F5 (12-2002)

 

Page 2

 

 

PART V – FOOD STAMPS

19.

 

Your Answer

Spouse’s Answer, if filing

 

Are you currently receiving food stamps or has a food stamp

YES

NO

YES

NO

 

application been filed for you within the past 60 days on which

 

 

 

 

 

 

there has not been a decision?

 

 

 

 

20.

If “No”, do you want to apply for food stamps?

Your Answer

Spouse’s Answer, if filing

 

YES

NO

YES

NO

 

 

PART VI – MISCELLANEOUS

ANSWER #21 ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISE, GO TO #22.

21.Name of Person Requesting Benefits

Relationship to Claimant

Your Social Security Number

PART VII – REMARKS – Use this space for any explanations.

Form SSA-8001-F5 (12-2002)

Page 3

REMARKS (CONTINUED)

IMPORTANT INFORMATION – PLEASE READ CAREFULLY

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.

If you are disabled or blind, you must accept any appropriate vocational rehabilitation services offered to you by the State agency to which we refer you.

PART VIII – SIGNATURES

I / We declare under penalty of perjury that I/we 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/our knowledge.

22. Your Signature (First name, middle initial, last name) (Write in ink)

Date (month, day, year)

 

 

 

Telephone number(s) at which you

 

may be contacted during the day

 

 

23.Spouse’s Signature (First name, middle initial, last name) (Write in ink)

(Sign only if applying for payments.)

24.

Applicant’s Mailing Address (Number and street, apt. no., P.O. box or rural route)

 

City and State

ZIP Code

Enter name of county (if any) in

 

 

 

which you live

 

 

 

 

25.Claimant’s Residence Address (If different from applicant’s mailing address)

 

City and State

ZIP Code

Enter name of county (if any) in

 

 

 

which the claimant lives

 

 

 

 

WITNESSES

26.

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 addresses.

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-F5 (12-2002)

Page 4

How to Edit Ssa 8001 F5 Form Online for Free

Working with PDF documents online is actually super easy using our PDF editor. Anyone can fill in ssa f5 here with no trouble. Our editor is continually developing to deliver the very best user experience attainable, and that's because of our commitment to constant development and listening closely to customer feedback. With just a few simple steps, you are able to start your PDF journey:

Step 1: Hit the "Get Form" button above on this webpage to access our PDF editor.

Step 2: The tool grants the opportunity to modify PDF documents in many different ways. Enhance it by adding personalized text, adjust what is originally in the file, and add a signature - all when you need it!

Be mindful while filling out this form. Ensure that all mandatory blanks are completed properly.

1. To start with, when completing the ssa f5, start with the section with the following blanks:

ssa 8001 for 2018 writing process detailed (step 1)

2. When the last array of fields is done, you're ready insert the essential specifics in Other Names and Social Security, a Your Other Names including, b Spouses Mothers Other Names, c Fathers Other Names, Your Place of Birth City and, Your Other Social Security Numbers, Spouses Mothers Other Social, If you or your spouse parents are, Spouses Place of Birth City and, Your Answer, Date Impairment began, Spouses Mothers Answer, Fathers Answer, and Type of impairment in order to proceed to the next part.

Guidelines on how to complete ssa 8001 for 2018 stage 2

3. This next stage is normally straightforward - fill out all of the empty fields in NOTE If you and your spouse, Your Answer, Spouses Answer if filing, admitted for permanent residence, b If you are lawfully admitted for, YES, YES, DATE month day year, DATE month day year, NOTE If the individual or spouse, Form SSAF, and Page to conclude the current step.

Part number 3 of completing ssa 8001 for 2018

People frequently make some errors when filling in b If you are lawfully admitted for in this area. Don't forget to read again everything you type in right here.

4. This fourth subsection comes with the following fields to enter your specifics in: the best description, House apartment mobile home room in, a commercial establishment, School rehabilitation center rest, nursing home hospital or jail, Room in a private home Foster Home, Mark the box that describes with, do not answer but explain in, Alone, Spouse Parents and Children, Other People, PART III RESOURCES, Show resources as of the first, If you own or your name or your, and Description.

Stage no. 4 in completing ssa 8001 for 2018

5. This form needs to be concluded by dealing with this segment. Further you can see a comprehensive listing of form fields that must be filled out with specific details to allow your form usage to be faultless: d Vehicles cars trucks boats, e Property other than the home you, f Life estates or property you, g Other items that can be turned, Are any items listed in question, Your Answer Spouse Mothers Answer, Yes, Yes, Yes, PART IV INCOME List all income, List cash checks and direct, Person Receiving, Income, Type of Income, and Amount.

List cash checks and direct, PART IV INCOME List all income, and d Vehicles cars trucks boats inside ssa 8001 for 2018

Step 3: Prior to finishing your form, you should make sure that all form fields have been filled out the right way. Once you think it is all good, press “Done." Get hold of your ssa f5 when you sign up for a free trial. Quickly access the document from your personal cabinet, together with any edits and adjustments automatically preserved! At FormsPal.com, we endeavor to make sure all of your information is maintained protected.

Ssa 8001 F5 Form isn’t the one you’re looking for?

Related Documents