Form SSA-8001-BK at a glance
What it is: Form SSA-8001-BK is the Social Security Administration's application for Supplemental Security Income (SSI), Deferred or Abbreviated, and any federally administered state supplementation.
Where and when to file: Send or bring the completed form to your local Social Security office.
Who signs: Write your Signature (First name, middle initial, last name) in ink, and the Date (MM/DD/YYYY). Write the Spouse's Signature (First name, middle initial, last name) in ink. Sign only if applying for payments.
A filled-in Form SSA-8001-BK example: an individual claim
How to fill out Form SSA-8001-BK, box by box
Type of Claim
Under TYPE OF CLAIM, the boxes are Individual, Individual with Ineligible Spouse, Couple, Child and Child with Parent(s).
Name, Birthdate and Social Security Number
In Part 1, answer the questions beginning with the first moment of the filing date month.
Enter your First Name, Middle Initial, Last Name, Birthdate (MM/DD/YYYY) and Social Security Number.
Are you married?
In 4(a), Are you married? If NO, go to #5.
For (b), enter the Date of Marriage (MM/DD/YYYY).
For (c), Are you and your spouse living together? If no, enter the date you began living apart.
Signing the application
Write your Signature (First name, middle initial, last name) in ink, and the Date (MM/DD/YYYY).
Write the Spouse's Signature (First name, middle initial, last name) in ink. Sign only if applying for payments.
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.
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.
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.
More rules for Form SSA-8001-BK
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.
If your situation is different
Part 2: where and with whom you live
In 19(a), mark the box that describes where you live.
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.
Part 3: Resources
Show resources as of the first moment of the filing date month.
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.
The items are (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. The items go on with (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 and (n) Other Resource.
Part 4: Income
List cash, checks, and direct payment to bank accounts you (your spouse/parent(s)) 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.
Money or property sold, transferred or given away
Have you or your spouse sold, transferred title, disposed of or given away, any money or other property, including money or property in foreign countries, since the first moment of the filing date month or within the 36 months prior to filing date month?
Permission to obtain financial records
Do you give permission to obtain any financial records from any financial institution?
Permission is asked to obtain, from any financial institution, any financial record about you that is held by the institution. Financial institutions are asked for this information whenever it is needed to decide if you are eligible or if you continue to be eligible for SSI benefits.
Once authorized, the permission to contact financial institutions remains in effect until one of the following occurs: (1) you or your spouse notify 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) your spouse's income and resources are no longer considered 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 the Social Security Administration may deny your claim or stop your payments.
Before you go
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).
Common questions about Form SSA-8001-BK
Where do I file it?
Send or bring the completed form to your local Social Security office.
Sources
[1] Form SSA-8001-BK (07-2023), Application for Supplemental Security Income (SSI), Social Security Administration (the Official source link on this page).