Ssa 8006 F4 Form – Fill Out and Use This PDF

The SSA-8006-F4 form, authorized by the Social Security Administration, is critically important for documenting an individual's living arrangements, in-kind support, and maintenance. It plays a vital role in determining eligibility and the correct benefit amount for Supplemental Security Income (SSI) recipients. Understanding and correctly completing this form can significantly impact one's SSI benefits, making it essential for claimants to provide detailed and accurate information about their living situation and any support they receive.

If you need to update or provide information regarding your living arrangements for SSI benefits, click the button below to fill out the SSA-8006-F4 form diligently.

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Ssa 8006 F4 Form PDF Details

Navigating the bureaucracy of social services can often seem like an overwhelming task, especially when it involves understanding the complexities of various forms required by the Social Security Administration (SSA). One such form, the SSA-8006-F4, titled "Statement of Living Arrangements, In-Kind Support, and Maintenance," serves as a critical piece of documentation for individuals seeking Supplemental Security Income (SSI). This form does more than just collect basic information; it delves into the specifics of an applicant’s living situation, household composition, and the nuances of financial support that they may be receiving. By gathering details on whether an individual lives alone or with others, owns or rents their home, and any contributions towards household expenses or receipt of in-kind support, the SSA can make informed decisions regarding eligibility and benefit amounts. Furthermore, the form not only captures changes in the claimant's living conditions and support but also underscores the importance of truthful reporting, highlighting potential consequences for non-compliance. With sections tailored to initial claims and post-eligibility scenarios, the SSA-8006-F4 encapsulates the agency's efforts to ensure that assistance is accurately allocated based on the current circumstances of each applicant, thereby upholding the integrity of the social security system.

Question	Answer
Form Name	Ssa 8006 F4 Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	SSI, OMB, Posteligibility, CLAIMANT

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	Form Approved
SOCIAL SECURITY ADMINISTRATION	OMB No. 0960-0174

STATEMENT OF LIVING ARRANGEMENTS, IN-KIND SUPPORT AND MAINTENANCE

CLAIMANT'S/RECEIPIENT'S NAME (Print, first, middle initial, last)

CLAIMANT'S/RECIPIENT'S SOCIAL SECURITY NUMBER

CLAIMANT'S/RECEIPIENT'S SPOUSE'S NAME (Print if spouse applying or receiving benefits)

SPOUSE'S SOCIAL SECURITY NUMBER

DATE OF CHANGE OF LIVING SITUATION (If applicable)

TYPE OF CHANGE (Change of residence, household composition, contribution amount, etc.)

THIS SSA-8006-F4 COVERS THE PERIOD BEGINNING		THROUGH

PART I

Initial Claims: Complete Part I when a change in living arrangement occurs after claim is filed and claim is pending.

Posteligibility: Complete Part I when response(s) to questions on the SSA-8202 (short form Statement for Determining Continuing Eligibility for Supplemental Security Income Payments) require additional living arrangement development.

1.CHECK THE BLOCKS WHICH BEST DESCRIBE YOUR LIVING ARRANGEMENTS A. I live (with):

Alone

Eligible spouse

Ineligible spouse

Parent(s)

Child(ren)

Essential person

Other people

Sponsor

B. I live in a:

House

Apartment

Room (Commercial establishment)

Room (private home)

Mobile home

Other (specify)

C. Total number of people in household

(including yourself)

2.CHECK ''YES'' OR ''NO'' TO THE FOLLOWING QUESTIONS AND PROVIDE ADDITIONAL INFORMATION AS REQUESTED.

A. Do you (and/or your spouse, or deemor) own or are you (and/or your		YES	NO

spouse, or deemor) buying the home you live in? If "yes", go to question 3.


B. Do you (and/or your spouse, or deemor) rent the place where you live?		YES	NO
If ''yes,'' go to D.		YES	NO

C. Does anyone who lives with you rent the place where you live?		YES	NO

If ''no,'' go to question 3.

D. Are you or anyone you live with related to the landlord		YES	NO
D. Are you or anyone you live with related to the landlord
(landlord's spouse)?
(landlord's spouse)?

If ''yes,'' indicate relationship	4
	4

E. If you answered ''yes'' to B. or C., provide the following information:

LANDLORD'S NAME		LANDLORD'S ADDRESS

LANDLORD'S PHONE NUMBER	DATE RENTAL AGREEMENT BEGAN		MONTHLY RENTAL AMOUNT
	month	year	$
			$

Form SSA-8006-F4 (3-94)

3. DOES ANY AGENCY, ORGANIZATION OR ANYONE WHO DOES NOT LIVE
	WITH YOU PAY, OR HELP YOU PAY FOR ANY OF THE FOLLOWING ITEMS:	YES	NO
	FOOD, RENT, HOME MORTGAGE PAYMENTS, PROPERTY INSURANCE (IF	YES	NO
	FOOD, RENT, HOME MORTGAGE PAYMENTS, PROPERTY INSURANCE (IF
	REQUIRED BY MORTGAGE HOLDER), REAL PROPERTY TAXES, HEATING
	FUEL, GAS, ELECTRICITY, GARBAGE REMOVAL, WATER AND/OR SEWER
	BILLS?

If ''yes,'' please provide the following information about each item you receive, then go to question 4.

ITEM	NAME, ADDRESS AND TELEPHONE NUMBER OF CONTRIBUTOR			FREQUENCY	IN	IN	DOLLAR
ITEM				OF	IN	IN	DOLLAR
	NAME	ADDRESS	TELEPHONE NUMBER	PAYMENT	CASH	KIND	VALUE
	NAME	ADDRESS	TELEPHONE NUMBER	PAYMENT

4. IF YOU DO NOT LIVE WITH OTHERS, SKIP TO PART III. IF YOU LIVE WITH			YES	NO
	OTHERS, DO ALL THE OTHER HOUSEHOLD MEMBERS RECEIVE SOME TYPE		YES	NO

	OF PUBLIC PAYMENT BASED ON NEED (e.g., AFDC, BIA, SSI, VA)?
	If ''Yes,'' indicate from which agency, then go to Part Ill.		AGENCY NAME

	If ''No,'' go to Part II.	4
		4

PART II

Complete Part II when individual lives with at least one person other than, or in addition to, spouse, child(ren), or person whose income may be deemed to the individual.

1.CHECK ''YES'' OR ''NO'' TO THE FOLLOWING QUESTIONS OR PROVIDE THE INFORMATION REQUESTED. A. Do you eat all your meals out?

	If ''Yes,'' go to C.			YES	NO
	If ''No,'' go to B.

	B. Do you buy all of your food separately from other household members?			YES	NO

	C. How much is your average cash contribution per month toward the
	household expenses listed in 4. below.	4	$
	household expenses listed in 4. below.		$


	D. Do you have an agreement to pay back the people you live with for your			YES	NO
	share of the household expenses?			YES	NO
	share of the household expenses?

2.	IF YOU OR YOUR SPOUSE OWN OR RENT, SHOW THE TOTAL MONTHLY
	IF YOU OR YOUR SPOUSE OWN OR RENT, SHOW THE TOTAL MONTHLY
	CASH CONTRIBUTIONS FROM OTHERS WITH WHOM YOU LIVE:		$

3.CHECK ''YES'' OR ''NO'' TO THE FOLLOWING QUESTIONS AND PROVIDE ADDITIONAL INFORMATION AS REQUESTED ONLY IF YOU ANSWERED ''NO'' TO BOTH QUESTIONS 1.A. AND 1.B. AND YOU DO NOT OWN OR RENT THE PLACE WHERE YOU LIVE.

A. Is part or all of the amount in question 1.C. just		YES	NO
		YES	NO

for food?	HOW MUCH?
4	$
4	$
B. Is part or all of the amount in question 1.C. just		YES	NO
		YES	NO

for shelter?	HOW MUCH?
4	$
4	$

Form SSA-8006-F4 (3-94)

WHAT IS THE AVERAGE MONTHLY AMOUNT OF THE FOLLOWING HOUSEHOLD CASH EXPENSES FOR THE PERIODS INDICATED?

	FROM	THROUGH FROM	THROUGH FROM	THROUGH
CASH EXPENSES
CASH EXPENSES

Food (Complete only if both 1.A. and 1.B. above	$	$	$
are answered "no")	$	$	$
are answered "no")

Mortgage or rent

Property insurance (if required by mortgageholder)

Real property taxes

Heating fuel

Electricity

Gas

Water

Sewer

Garbage removal

Total

REMARKS: You may use this space for any explanations. Enter the item number before each explanation. If you need more space, use a signed SSA-795.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security Office.

The Paperwork Reduction act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.

TIME IT TAKES TO COMPLETE THIS FORM

We estimate that it will take you about 7 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235-0001. Send only comments relating to our ''time it takes'' estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.

Form SSA-8006-F4 (3-94)

PART III

YOUR RESPONSIBILITIES: Anyone who knowingly and willfully makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal or State law or both.

Do you understand that the information provided is subject to verification and do you	YES	NO

authorize sources to release to the Social Security Administration information needed to

verify your statements?

Do you understand that if there is any change in the information you have provided on	YES	NO

this statement that you must report it to the Social Security Administration because your

eligibility or benefit amount could be affected?

Do you understand that failure to report any change could result in a penalty to you of	YES	NO

$25 to $100 if the report is not made within 10 days after the end of the month in which

the change occurred?

Do you affirm that all the information you gave in this document or in support of it is	YES	NO

true?

COLLECTION AND USE OF INFORMATION FROM YOUR STATEMENT OF LIVING ARRANGEMENTS

PRIVACYACT/PAPERWORK REDUCTION ACT NOTICE

The Social Security Administration (SSA) is authorized to collect the information on this form under section 1631 (e) of the Social Security Act, as amended (42 U.S.C. 1383) (e)). While it is not mandatory for you to furnish the information on this form to SSA, failure to provide all or part of the information could prevent an accurate and timely decision on your claim and could result in the loss of some payments. Your response is mandatory where the refusal to disclose certain information affecting your right to payment would reflect a fraudulent intent to secure payments not authorized by the Social Security Act.

Although the information you furnish on this form is almost never used for any other purpose than stated in the foregoing, there is a possibility that information may be disclosed to another person or to another governmental-agency as follows: 1) to enable a third party or an agency to assist SSA in establishing rights to supplemental security income payments 2) to comply with Federal laws requiring the release of information from SSA records (e.g., to the Veterans Administration) and 3) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the social programs (e.g., to the Bureau of the Census and private concerns under contract to SSA).

SIGNATURES

YOUR SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)

DATE (MONTH, DAY, YEAR)

SIGN
HERE

SPOUSE'S SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) (WRITE IN INK)		TELEPHONE NUMBER(S) AT WHICH YOU MAY BE
		CONTACTED DURING THE DAY (INCLUDE AREA CODE)
SIGN
HERE

MAILING ADDRESS (NUMBER AND STREET, APT. NO., P.O. BOX OR RURAL ROUTE)

CITY AND STATE	ZIP CODE	ENTER NAME OF COUNTY (IF ANY)

NOTE: If residence address is different from mailing address, show in ''Remarks''

This statement 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-8006-F4 (3-94)	4	* U S. Government Printing Office: 1998 - 433-335/80213

How to Edit Ssa 8006 F4 Form Online for Free

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2. Immediately after this section is filled out, go to type in the suitable details in these: House, Apartment, Room Commercial establishment, Room private home, Mobile home, Other specify, C Total number of people in, CHECK YES OR NO TO THE FOLLOWING, A Do you andor your spouse or, B Do you andor your spouse or, C Does anyone who lives with you, D Are you or anyone you live with, If yes indicate relationship, E If you answered yes to B or C, and LANDLORDS NAME.

3. Completing DOES ANY AGENCY ORGANIZATION OR, YES, If yes please provide the, ITEM, NAME ADDRESS AND TELEPHONE NUMBER, NAME, ADDRESS, TELEPHONE NUMBER, FREQUENCY, PAYMENT, CASH, KIND, DOLLAR VALUE, IF YOU DO NOT LIVE WITH OTHERS, and YES is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

4. To go forward, this next section involves typing in a handful of form blanks. Examples of these are A Do you eat all your meals out, If Yes go to C If No go to B, B Do you buy all of your food, C How much is your average cash, household expenses listed in below, YES, YES, D Do you have an agreement to pay, share of the household expenses, YES, IF YOU OR YOUR SPOUSE OWN OR RENT, CHECK YES OR NO TO THE FOLLOWING, ONLY IF YOU ANSWERED NO TO BOTH, A Is part or all of the amount in, and for food, which are fundamental to carrying on with this particular document.

CHECK YES OR NO TO THE FOLLOWING, A Do you eat all your meals out, and A Is part or all of the amount in of SSA-795

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Ssa 8006 F4 Form – Fill Out and Use This PDF

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