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Form Name	Ssa 8203 Bk Form
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SOCIAL SECURITY ADMINISTRATION	UPDATE	FORM APPROVED
SOCIAL SECURITY ADMINISTRATION		OMB No. 0960-0416
		OMB No. 0960-0416

STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY		For Official Use Only
FOR SUPPLEMENTAL SECURITY INCOME PAYMENTS	EI SSN

Name and Address	Spouse's Name
	Spouse's SSN

	Check the Ones That Apply			DO Code
	C	NC
	M	N
	FS-APP	FS-REF

	Interviewer's Initials		Date Received

WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE

	MARITAL STATUS/TRAVEL OUTSIDE THE UNITED STATES/LIVING ARRANGEMENTS
1.	Since the date above, has your marital status (or the marital status of your parents if you are a child)					Yes	No
	changed?					Yes	No
	changed?
2.	Since the date above, have you moved to a new address?					Yes	No
	If ''yes,'' give the new address:					Yes	No
	If ''yes,'' give the new address:

	ADDRESS (Number, Street, City, State, and ZIP Code)				DATE YOU MOVED
					DATE YOU MOVED

3.	Since the date above, have you been outside the United States (the 50 States, District of Columbia, and					Yes	No
	Northern Mariana Islands)?					Yes	No
	If "yes," please give:
	DATE(S) LEFT (month/day/year):		DATE(S) RETURNED (month/day/year)

4.	Since the date above, have you spent a full calendar month in a hospital, nursing home, or other					Yes	No
	institution?					Yes	No
	If ''yes,'' please give:
	NAME OF INSTITUTION	DATE ENTERED (Month/day/year):		DATE LEFT (Month/day/year):

		ADDRESS (Number, Street, City, State and ZIP Code)

5.Mark X in the box which best describes where you live:

House	Room	Nursing Home	Hospital	School
House	Room	Nursing Home	Hospital	School
Apartment	Mobile Home	Rest or Retirement Home	Rehabilitation Center	Other

(specify)

Since the date above, has anyone moved into or out of the place where you live? (including births and

Yes

deaths) If "yes," please give:

BLIND OR

DATE MOVED

INELIGIBLE CHILD

NAME

RELATIONSHIP

AGE

DISABLED

YES

OUT

STUDENT

MARRIED

INCOME

7.	Do any other people live in the same household with you or your spouse?								Yes	No
	If "yes," please give the following information about them (including children):								Yes	No


			AGE AND/OR	BLIND OR		INELIGIBLE CHILD
	NAME	RELATIONSHIP	AGE AND/OR	DISABLED		INELIGIBLE CHILD
	NAME	RELATIONSHIP	DATE OF BIRTH	YES	NO	STUDENT	MARRIED	INCOME

Form SSA-8203-BK (5-2003) EF (06-2003) Destroy Prior Editions

Page 1

LIVING ARRANGEMENTS (continued)

Do all of the people who live with you receive public assistance payments?

Yes

(For example, welfare, AFDC/TANF, VA pension, general assistance, SSI.)

Do you, or your spouse living with you, own or are you buying the place where you live?

Yes

If "yes," give:

MONTHLY MORTGAGE PAYMENT AMOUNT:

b. Do you, or your spouse living with you, rent the place where you live?

Yes

c. If you are a child recipient living with your parents, do your parents own or rent the place where you live?

Yes

d. Does someone else who lives with you own or rent the place where you live?

Yes

e. If the place where you live is rented give,

LANDLORD'S NAME

ADDRESS

LANDLORD'S

MONTHLY

(Number, Street, City, State and ZIP Code)

PHONE

RENT

(

)

If the place where you live is rented, are you (or anyone living with you) the parent or child of your

Yes

landlord or your landlord's spouse?

If "yes," give the name of the household member who is the

related person

g. If a. or b. is answered "yes," does any one who lives with you (other than your spouse) pay for or give

you money for food, mortgage or rent, property insurance or taxes, heating fuel, gas, electricity, water,

Yes

sewerage, or garbage collection services?

10.

Since the date on page 1, did anyone not living with you:

Yes

a. Give you a free place to live?

b. Help you pay the mortgage, rent, property insurance, property taxes, and/or sewerage charges?

Yes

c. Give you or help you pay for food, gas, electricity, heating fuel, water, and/or garbage collection service?

Yes

If "yes," to a., b., or c., complete the following:

SOURCE

PHONE

MONTHLY

MONTHS

TYPE OF HELP

NAME/ADDRESS (Number, Street, City, State, ZIP Code)

NUMBER

AMOUNT

RECEIVED

(

)

(

)

(

)

11.

Since the date on page 1, did anyone five you clothing or other gifts which are not cash?

Yes

If "yes," complete the following:

DESCRIPTION OF

SOURCE

PHONE

MONTHS

VALUE

ARTICLE

NAME/ADDRESS (Number, Street, City, State, ZIP Code)

NUMBER

RECEIVED

(

)

(

)

EARNED INCOME

12.

Since the date on page 1, have you, or your spouse living with you, worked OR do you expect to

Yes

work in the next 14 months?

If "yes," please give:

a. Amounts for Past Months

NAME OF

GROSS WAGES

EMPLOYER'S NAME, ADDRESS (Number, Street, City,

How

DATES OF

WORKER

EMPLOYMENT

State, ZIP Code) AND PHONE NUMBER

Amount

Often

Paid

From:

To:

From:

To:

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 2

12.	EARNED INCOME (continued)

b. Estimates for Current and Future Months

Month

	Amount	$	$	$	$	$	$	$	$
		$	$	$	$	$	$	$	$

	Month

	Amount	$	$	$	$	$	$	$	$
		$	$	$	$	$	$	$	$

13.	Since the date on page 1, have you, or your spouse living with you, been self-employed or expect to be									Yes	No
	self-employed in the current taxable year?									Yes	No
	self-employed in the current taxable year?
	If ''yes,'' please give:

					LAST YEAR'S		THIS YEAR'S ESTIMATED
	NAME OF SELF-EMPLOYED		TYPE OF BUSINESS		GROSS	NET INCOME	GROSS	NET INCOME	DATES OF SELF-
	PERSON		TYPE OF BUSINESS		GROSS	NET INCOME	GROSS	NET INCOME	EMPLOYMENT
	PERSON				INCOME	(OR LOSS)	INCOME	(OR LOSS)	EMPLOYMENT
					INCOME	(OR LOSS)	INCOME	(OR LOSS)
									From:
									To:

									From:
									To:

14.	If you are disabled, do you have any special expenses that you paid that are related to your illness or injury									Yes	No
	and which are necessary for you to work?									Yes	No
	and which are necessary for you to work?
					UNEARNED INCOME

15.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:

a. Private pensions, annuities (other than Social Security, SSI, or food stamps)?						Yes	No

b. Unemployment or worker's compensation?						Yes	No

c. TANF, AFDC or State or local assistance based on need?						Yes	No

d. Veterans Administration benefits (based on need, not based on need, education)?						Yes	No

e. Rental/lease income?						Yes	No

f. Alimony or child support?						Yes	No

g. Dividends or royalties?						Yes	No

h. Interest earned on money in bank accounts (including interest on checking accounts)?						Yes	No

i. Money from a trust fund?						Yes	No

j. Money from any other person or organization?						Yes	No

If the answer is ''yes,'' to any of these types of unearned income, please give:

TYPE OF	RECEIVED BY	AMOUNT	FREQUENCY	DATES RECEIVED OR	SOURCE (Name/Address of Person,
INCOME				EXPECTED	Bank, Company, or Organization)

				From:
				To:

				From:
				To:

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 3

16.

RESOURCES: THINGS YOU OWN

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):

a. Cash (with you, at home, in a safe deposit box)?

Yes

b. Checking accounts?

Yes

c. Savings accounts?

Yes

d. Credit union accounts?

Yes

e. Christmas club accounts?

Yes

f. Savings certificates/certificates of deposit?

Yes

g. Promissory notes or IOU's?

Yes

h. Stocks or bonds?

Yes

i. Other items that can be cashed or sold?

Yes

If "yes," please give the following information:

NAME OF

OWNER(S) OF

TOTAL VALUE

NAME AND ADDRESS OF BANK,

EACH ITEM

OF EACH ITEM

COMPANY, OR ORGANIZATION

17.

Do you, or your spouse living with you, own or are you buying any life insurance policies?

Yes

If ''yes,'' please give the following information:

NAME OF OWNER

NAME OF INSURED

NAME AND ADDRESS OF INSURANCE COMPANY

POLICY NUMBER

TOTAL FACE VALUE

CASH SURRENDER

WHEN WAS THE

IF THERE IS A LOAN AGAINST

OF POLICY

VALUE

POLICY PURCHASED

THE POLICY, GIVE THE AMOUNT

18.

Is your name, or the name of your spouse living with you, on the title of any vehicles (for example, car,

Yes

truck, boat, camper, motorcycle, etc.)? If "yes," please give the following information:

NAME OF OWNER(S)

YEAR OF

MAKE AND MODEL

CURRENT

HOW MUCH IS OWED

VEHICLE(S)

MARKET VALUE

ON VEHICLE(S)

MAIN PURPOSE FOR WHICH THE VEHICLE(S) IS USED (For example, employment, to obtain medical treatment, etc.)

19.

Do you, or your spouse living with you, own or are you buying any real estate (land or buildings or other

Yes

structures on the land)? (Include property outside the U.S., inherited property, life estates. Do not include

your home.) If "yes," please give the following information:

NAME OF OWNER

ESTIMATED CURRENT

TAX ASSESSED

AMOUNT OF MORT-

AMOUNT OWED ON

MARKET VALUE

VALUE IF KNOWN

GAGE PAYMENT (if any)

THE PROPERTY

DESCRIPTION (Include type and size of structures,

USE (Describe how the property is used. If not in use, give

acreage or lot size, and location of property)

date of last use and next planned use.)

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 4

RESOURCES (continued)

20. Do you, or your spouse living with you, own any of the following items (answer "yes" if your name or your
	spouse's name appears alone or with any other person as the owner or part owner of any of these items).				Yes	No
	a. Other household or personal items not already mentioned worth more than $500?				Yes	No


	b. Other equipment (business or nonbusiness) or property of any kind (not already included on this form)?
	If "yes," please give the following information:				Yes	No
	If "yes," please give the following information:

	OWNER(S) OF EACH ITEM	NAME OF EACH ITEM	TOTAL VALUE	HOW MUCH IS OWED ON
	OWNER(S) OF EACH ITEM	NAME OF EACH ITEM	OF EACH ITEM	EACH ITEM
			OF EACH ITEM	EACH ITEM

DESCRIPTION (Where appropriate, give name	USE (Describe how the property is used. If not in use,
and address of bank, company, or organization)	give date of last use and next planned use.)

21.a. Do you, or your spouse living with you, own any headstones or markers, cemetery lots, crypts, urns,

mausoleums, or other repositories for burial?

Yes

If ''yes,'' please give:

NAME OF OWNER	FOR WHOSE BURIAL	RELATIONSHIP TO YOU	DESCRIPTION AND VALUE
		OR YOUR SPOUSE

b. Do you, or your spouse living with you, have any money or other assets, such as, burial contracts,
trusts, insurance policies, agreements, or anything else you intend to use for your burial expenses?					Yes	No
(Include assets listed in items 16-21 if appropriate.)
If ''yes,'' please give:
		WHEN DID YOU SET IT	WILL INTEREST EARNED OR APPRECIATIONS
DESCRIBE WHAT YOU HAVE SET ASIDE	VALUE		IN VALUE REMAIN IN THE BURIAL FUND
DESCRIBE WHAT YOU HAVE SET ASIDE	VALUE	ASIDE (Month/Day/Year)

			YES	NO
			YES	NO

IS IT IRREVOCABLE		NAME OF OWNER	FOR WHOSE BURIAL

YES	NO
YES	NO

22.	a. Since the date on page 1, have you, your spouse living with you, sold, transferred	You	Yes	No
		You	Yes	No
	title, disposed of or given away any money, or other property, including money or		Yes	No
		Your Spouse
	property in foreign countries?	Your Spouse

	b. If you co-owned property with another person(s), did you or any co-owner sell, transfer,	You	Yes	No
	or give way any co-owned money or property?	You	Yes	No
	or give way any co-owned money or property?
		Your Spouse	Yes	No

	IF ''YES'' TO (A) OR (B), GO TO (C). IF NO TO BOTH, GO TO 23.

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 5

RESOURCES (continued)

22.

SOLD ON

GIVEN

TRADED FOR

OWNER'S/CO-OWNER'S NAME(S)

DATE OF

OPEN MARKET

AWAY

GOODS/SERVICES

DISPOSAL

Cont.

DESCRIPTION OF PROPERTY

NAME AND ADDRESS OF

RELATIONSHIP

PURCHASER OR RECIPIENT

TO OWNER

VALUE OF PROPERTY AND/OR

SALE PRICE OR OTHER

ARE ADDITIONAL CONSIDERATION OR PROCEEDS EXPECTED?

AMOUNT OF CASH GIFT

CONSIDERATION RECEIVED

EXPLAIN

DO YOU STILL OWN PART OF THE PROPERTY? IF YES, EXPLAIN

Yes

23.

Since the date on page 1, have you (or your spouse living with you) had any change in health insurance

coverage or other insurance that pays for medical bills?

(Do not include Medicare, but do include insurance

Yes

such as accident, automobile, or casualty if it covers medical bills for any reason.)

IF YOU LIVE IN CALIFORNIA, PLEASE DO NOT ANSWER QUESTION 24 BELOW.

24.

a. Are you currently receiving food stamps? If YES, go to ''b." If NO, go to "c."

b. Have you received a recertification notice within the past 30 days? If YES, go to "e." If NO, go to question 25.

c. Have you filed for food stamps in the last 60 days? If YES, go to "d." If NO, go to "e."

d. Have you received a favorable decision? If YES, go to question 25. If NO, go to e.

e. Is everyone in the household applying for or receiving SSI? If YES, go to ''f." If NO, go to question 25.

f. May I take your food stamp application today? If YES, go to question 25. If NO, explain in ''g.''

g. Explanation

You
YES	NO
YES	NO
YES	NO
YES	NO
YES	NO
YES	NO

Your Spouse

YES	NO
YES	NO
YES	NO
YES	NO
YES	NO
YES	NO

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 6

25.	a. Which language do you prefer to use when speaking to us?
	b. Which language do you prefer us to use when writing to you?

26.	Please answer the following questions:
	a. Are you age 62 or older?		Yes	No

	b. If you are age 50 or older, are you a widow(er)?		Yes	No
			Yes	No

	c. If you are age 50 or older and divorced, is your divorced spouse deceased?		Yes	No

	d. If you were disabled before age 22, do you have a parent who is age 62 or older, disabled, or		Yes	No
	deceased?		Yes	No
	deceased?
	WE ARE REQUIRED BY LAW TO ASK THE FOLLOWING QUESTIONS OF ALL SSI RECIPIENTS

27.	a. Have you been convicted of, or charged with a crime, or an attempt to commit a crime, which is a
	felony, or in New Jersey, a high misdemeanor?		Yes	No
	If ''yes,'' in which state did this occur?	Answer b.

	b. Since the date on page 1, have you been fleeing prosecution for that crime or fleeing to avoid custody or
	confinement after conviction?		Yes	No
	If ''yes,'' explain below (provide warrant information, if available):

28.	a. Have you been subject to a condition of parole or probation under Federal or state law?		Yes	No
	If "yes," answer b.		Yes	No
	If "yes," answer b.

	b. Since the date on page 1, have you violated a condition of your probation or parole?
	If "yes," explain below (provide warrant information, if available):		Yes	No

REMARKS

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 7

REMARKS Continued

If the address where you live is different than the address where you get your mail, please give the address where you live:

Address (Number and Street)	City/State

YOUR AUTHORIZATION

ZIP Code

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. I understand that the Social Security Administration will compare its records with records from other State and Federal agencies to make sure I am paid the correct amount of benefits. 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 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.

SIGNATURES (Write in ink)

Your Signature (First name, middle initial, last name)	Date		Area Code and Tele-
Sign			phone Number Where
Sign			You Can Be Reached
Here			You Can Be Reached
Here

Spouse's Signature (First name, middle initial, last name) (Sign Only if Receiving
	Date
SSI Payments)
SSI Payments)
Sign		(		)
Here		(		)

WITNESSES (Write in ink)

If you sign by mark (X), two people who know you must witness your signing. The witnesses must sign below and give their full names and addresses.

1. Signature of Witness

2. Signature of Witness

Address (Number, Street, City, State, ZIP Code)

REPRESENTATIVE PAYEE (Write in ink)

Your Title or Relationship to the Recipient

Area Code and Telephone Number Where You Can Be Reached

()

Address (Number, Street, City, State, ZIP Code)

Your full name (First name, middle initial, last name) Please print here

Date

Please sign here

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 8

RIGHTS AND RESPONSIBILITIES

NAME

SOCIAL SECURITY NUMBER

DATE

NAME

SOCIAL SECURITY NUMBER

DATE

Telephone Number (include area code) to call

Social Security Office you may visit in person or send in your request:

if you have a question or something to report.

(

)

Privacy Act Notice

The Social Security Administration is authorized to collect the information on this statement under 161 l(c) of the Social Security Act and regulations 20 CFR 416.204. While it is not mandatory except in the circumstances explained below, for you to furnish the information on this statement to Social Security, no benefits can continue unless a periodic review of eligibility is completed by a Social Security office. 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.

The information on this statement is needed to enable Social Security to determine if you continue to be eligible for supplemental security income (SSI) payments. Failure to provide all or part of the information could prevent an accurate and timely decision on your continuing eligibility for benefits.

Although the information you furnish on this statement 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 an agency as follows: 1. to enable a third party or an agency to assist Social Security in determining continuing eligibility to SSI payments; and

2.to comply with Federal law requiring the release of information from Social Security records (e.g., to the Department of Veterans Affairs)

COMPUTER MATCHING - 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.

PAPERWORK REDUCTION ACT: 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 XX minutes to read the instructions, gather the facts, and answer the questions. 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. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.

Reporting Responsibility

The amount of your SSI check is based on the information you tell us. To continue getting the right

payment amount, you must report certain changes that happen to you. Changes could make your check bigger or smaller.

You must tell us about changes within 10 days after the month they happen. If you do not report changes, we may have to take as much as $25, $50, or $100 out of future checks you receive.

You must also report changes in income for your ineligible spouse or children who live with you, or your sponsor or sponsor's spouse if you are an alien. You must also report if any of these people buy or sell anything of value.

A List of Most of the Changes You Must Report Is On The Next Page.

How To

Report

Changes

You can report changes in any of the following ways:

•Call us, toll free, at 1-800-772-1213.

•Call your local Social Security Office at the number at the top of this form.

•By mail or in person -- see the address at the top of this form.

Important

Facts About

Food Stamps

You can apply for food stamps at the Social Security Office if you and everyone in your household get or apply for SSI.

The Social Security Office will help you fill out the food stamp application. You do not have to go to the food stamp office to apply.

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 9

	CHANGES TO REPORT
WHERE YOU LIVE—You must report to Social Security if:
•	You move.	• You leave the United States for 30 days or more.
•	You (or your spouse) leave your household for	• You are released from a hospital, nursing home, etc.
		• You are no longer a legal resident of the United
	a calendar month or longer. For example,
		States.
	you enter a hospital or visit a relative.


HOW YOU LIVE—You must report to Social Security:		• Changes in your marital status:
•	If someone moves into or out of your household.
		- You get married, separated, divorced, or
•
	If the amount of money you pay toward	your marriage is annulled.
	household expenses changes.	- You separate from your spouse or start
•	If your former spouse dies.	living together again after a separation.
		- You begin living with someone as husband
•
	Births and deaths of any people with whom you live.	and wife.

- Your spouse dies.

INCOME—You must report to Social Security if:

•The amount of money (or checks or any other type of payment) you receive from someone or someplace goes up or down or you start to receive money (or checks or any other type of payment).

•You start work or stop work.

•Your earnings go up or down.

•You become eligible for benefits other than SSI.

HELP YOU GET FROM OTHERS—You must report to Social Security if:

• The amount of help (money, food, clothing, or	•	Someone stops helping you.
payment of household expenses) you receive	•
goes up or down.	•	Someone starts helping you.

THINGS OF VALUE THAT YOU OWN—You must report to Social Security if:

• The value of your resources goes over $2,000	•	You sell or give any things of value away.
when you add them all together ($3,000 if you	•
are married and live. with your spouse).	•	You buy or are given anything of value.

YOU ARE BLIND OR DISABLED—You must report to Social Security if:

•Your condition improves or your doctor says you can return to work.

•You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22—A report to Social Security must be made if:

•You are under age 18 and live with your parent(s), ask your parents to report if they have a change in income, a change in their marriage, a change in the value of anything they own, or either has a change in residence.

•You get married.

•There are changes in the income, school attendance (if between the ages of 18 and 21), or marital status of ineligible children who live in your household.

•You start or stop school.

YOUR IMMIGRATION AND NATURALIZATION SERVICE (INS) STATUS CHANGES—You must report any changes to Social Security.

YOU ARE A REPRESENTATIVE PAYEE—You must report to Social Security if:

•The person for whom you receive SSI checks has any of the changes listed above. (You may be held liable if you do not report changes that could affect the SSI recipient's payment amount, and he/she is overpaid.)

•You will no longer be able or no longer wish to act as the person's representative payee.

Form SSA-8203-BK (5-2003) EF (06-2003)

Page 10

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