Fillable Form SSA-8000-BK (06-2019) UF: I am/We are applying

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Form SSA-8000-BK (06-2019) UF: I am/We are applying

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Form SSA-8000-BK (06-2019) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 24
OMB No. 0960-0229
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Note: Social Security Administration staff or others who help people apply
for SSI will fill out this form for you.
I am/We are applying for Supplemental Security Income
and any federally administered state supplementation
under Title XVI of the Social Security Act, for benefits
under the other programs administered by the Social
Security Administration, and where applicable, for
medical assistance under Title XIX of the Social
Security Act.
Do Not Write in This Space
DATE STAMP
Filing Date (MM/DD/YYYY)
Receipt Protective
SNAP-SSA/APP SNAP-Referred
Preferred Language
Written: Spoken:
TYPE OF CLAIM Individual
Individual with
Ineligible Spouse
Couple Child
Child with
Parents
PART 1 - BASIC ELIGIBILITY - Answer the questions below beginning with the first moment of
the filing date month.
1.
(a) First Name, Middle Initial, Last Name Sex
Male
Female
Birthdate
(MM/DD/YYYY)
Social Security Number
(b) Did you ever use any other names (including maiden
name) or any other Social Security Numbers?
YES Go to (c) NO Go to (d)
(c) Other Name(s) Other Social Security Number(s) used
(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:
Parent 1's Name (s)
Parent 1's Other Name (s) (Including Name at Birth)
Parent 2's Name (s)
Parent 2's Other Name (s) (Including Name at Birth)
Go to #2
2.
Applicant's Mailing Address (Number & Street, Apt. No., P.O. Box, Rural Route)
City and State (U.S.)/State/Province/Region (Foreign) ZIP Code/Postal Code County/Country
3.
Claimant's Residence Address (If different from applicant's mailing address)
City and State (U.S.)/State/Province/Region (Foreign) ZIP Code/Postal Code County/Country
4.
DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL INSTITUTION)
Routing Transit Number Account Number
Checking
Savings
Enroll in Direct Express
Direct Deposit Refused
02/06/2018
✔
English
English
✔
Tiffany Anne Baxter
✔
04/16/2002
999-99-9999
✔
Ronald Baxter
C/O: Some City Children’s Shelter 123 Main Street
Some City, YY
12345
✔
✔
Form SSA-8000-BK (06-2019) UF Page 2 of 24
5.
(a) Are you married?
YES Go to (b) NO Go to #6
(b) Date of marriage: (MM/DD/YYYY)
(c) Spouse's Name (First, middle initial, last) Birthdate
(MM/DD/YYYY)
Social Security Number
(d) Did your spouse ever use any other names (including
maiden name) or Social Security Numbers?
YES Go to (e) NO Go to (f)
(e) Other Name(s) Other Social Security Number(s) Used
(f) Are you and your spouse living together?
YES Go to #6 NO Go to (g)
(g) Date you began living apart : (MM/DD/YYYY)
(h) Address of spouse or name of someone who knows where spouse is. (Complete only if spouse is age 65, blind
or disabled.)
6.
(a) Have you had any other marriages?
If never married, check this box
You
YES
Go to (b)
NO
Go to 6(c)
Your Spouse, if filing
YES
Go to (b)
NO
Go to 6(c)
(b) Give the following information about your prior marriages. If there was more than one prior marriage, show the
remaining information in Remarks. Go to #7.
YOU YOUR SPOUSE
FORMER SPOUSE'S NAME
(including maiden name)
BIRTHDATE
(MM/DD/YYYY)
SOCIAL SECURITY
NUMBER
DATE OF MARRIAGE
(MM/DD/YYYY)
DATE MARRIAGE ENDED
(MM/DD/YYYY)
HOW MARRIAGE ENDED
(c) Are you and another person living together in the same household and presenting to others or the community as a
married couple?
YES If YES, provide the date holding out began , then go to (d)*
NO Go to #7
(d) Other person's Name (First, middle initial, last) Other person's Social Security Number
*Use SSA-4178 to develop the holding out relationship.
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 3 of 24
7.
If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
(a) Are you unable to work because of illnesses,
injuries or conditions?
You
YES
Go to (b)
NO
Go to #8
Your Spouse
YES
Go to (b)
NO
Go to #8
(b) Enter the date you became unable to work.
(MM/DD/YYYY) (MM/DD/YYYY)
(c) Are you blind or do you have low vision even with
glasses or contacts?
You
YES
Go to (d)
NO
Go to (d)
Your Spouse
YES
Go to (d)
NO
Go to (d)
(d) If you were unable to work because of illnesses, injuries, or conditions before you were age 22, do you have a
parent who is age 62 or older, unable to work because of illnesses, injuries or conditions, or deceased?
YES
Parent's Name:
Social Security Number:
Address:
Parent's Name:
Social Security Number:
Address:
NO
Go to #8
(e) When did the child become disabled?
(MM/DD/YYYY)
Go to (f)
(f) Is the child blind or do they have low vision even with glasses or contacts?
YES
Go to (g)
NO
Go to (g)
(g) Does the child have a parent(s) who is age 62 or older, unable to work because of illness, injuries, or conditions,
or deceased?
YES
Parent's Name:
Social Security Number:
Address:
Parent's Name:
Social Security Number:
Address:
NO
Go to #8
8.
Birthplace City State Country (if other than the U.S.)
You
Your Spouse,
if filing Go to #9
06/01/2014
Some town
YY
Form SSA-8000-BK (06-2019) UF Page 4 of 24
9.
Are you a United States citizen by birth?
You
YES
Go to #15
NO
Go to #10
Your Spouse, if filing
YES
Go to #15
NO
Go to #10
10.
Are you a naturalized United States citizen?
YES
Go to #15
NO
Go to #11
YES
Go to #15
NO
Go to #11
11.
(a) Are you an American Indian born outside the United
States?
YES
Go to (b)
NO
Go to (c)
YES
Go to (b)
NO
Go to (c)
(b) Check the block that shows your American Indian status.
You Your Spouse, if filing
American Indian born in Canada
Go to #15
American Indian born in Canada
Go to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe Go to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe
Go to #15
Other American Indian
Explain in Remarks, then Go to (c)
Other American Indian
Explain in Remarks, then Go to (c)
(c) Check the block below that shows your current immigration status
You Your Spouse, if filing
Amerasian Immigrant
Go to #12
Amerasian Immigrant
Go to #12
Asylee
Date status granted:
Go to #14
Asylee
Date status granted:
Go to #14
Conditional Entrant
Date status granted:
Go to #14
Conditional Entrant
Date status granted:
Go to #14
Cuban/Haitian Entrant
Go to #14
Cuban/Haitian Entrant
Go to #14
Deportation/Removal Withheld
Date:
Go to #14
Deportation/Removal Withheld
Date:
Go to #14
Lawful Permanent Resident
Go to #12
Lawful Permanent Resident
Go to #12
Parolee for One Year
Go to #14
Parolee for One Year
Go to #14
Refugee
Date of entry:
Go to #14
Refugee
Date of entry:
Go to #14
Unknown/Other
Explain in Remarks, then Go to (d)
Unknown/Other
Explain in Remarks, then Go to (d)
(d) If you have status or have applied for status as the spouse, child, or parent of a child of a US citizen or lawfully
admitted permanent resident alien, Go to #13; otherwise Go to #15.
12.
If you are lawfully admitted for permanent residence:
(a) Date of Admission
You
(MM/DD/YYYY)
Your Spouse
(MM/DD/YYYY)
(b) Was your entry into the United States sponsored by
any person or promoted by an institution or group?
YES
Go to (c)
NO
Go to (d)
YES
Go to (c)
NO
Go to (d)
(c) Give the following information about the person, institution, or group, then Go to (d):
Name
Address
Telephone Number
✔
Form SSA-8000-BK (06-2019) UF Page 5 of 24
12.
(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?
You
Status:
(MM/DD/YYYY)
From:
To:
Your Spouse, if filing
Status:
(MM/DD/YYYY)
From:
To:
(e) If filing as an adult, did your parents ever work in the
United States before you were age 18?
You
YES
Go to (f)
NO
Go to #14
Your Spouse, if filing
YES
Go to (f)
NO
Go to #14
(f) Name and Social Security Number of parent(s) who worked.
Name Social Security Number
Name Social Security Number
13.
(a) Have you, your child or your parent, been subjected to
battery or extreme cruelty while in the United States?
You
YES
Go to (b)
NO
Go to #15
Your Spouse, if filing
YES
Go to (b)
NO
Go to #15
(b) Have you, your child, or your parent filed a petition
with the Department of Homeland Security for a
change in immigration status because of being
subjected to battery or extreme cruelty?
YES
Go to #14
NO
Go to #15
YES
Go to #14
NO
Go to #15
14.
Are you, your spouse, or parent an active duty member or
a veteran of the armed forces of the United States?
YES
Explain in
#60(b), then
Go to #15
NO
Go to #15
YES
Explain in
#60(b), then
Go to #15
NO
Go to #15
15.
(a) When did you first make your home in the United
States?
(MM/DD/YYYY) (MM/DD/YYYY)
(b) Have you lived outside of the United States since
then?
YES
Go to (c)
NO
Go to #16
YES
Go to (c)
NO
Go to #16
(c) Give the dates of residence outside the United States.
(MM/DD/YYYY)
From:
To:
(MM/DD/YYYY)
From:
To:
16.
(a) Have you been outside the United States (the 50
states, District of Columbia and Northern Mariana
Islands) 30 consecutive days prior to the filing date?
YES
Go to (b)
NO
Go to #17
YES
Go to (b)
NO
Go to #17
(b) Give the date (MM/DD/YYYY) you left the United
States and the date you returned to the United States.
Date Left:
Date Returned:
Date Left:
Date Returned:
IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #17.
IF YOU ARE MARRIED AND YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY INCOME AND
YOU LIVED TOGETHER AT ANY TIME SINCE THE FIRST MOMENT OF THE FILING DATE MONTH, GO TO
#17; OTHERWISE GO TO #18.
Go to (e)
✔
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 6 of 24
17.
(a) Is your spouse/parent the sponsor of an alien who is
eligible for supplemental security income?
YES Go to (b)
No Go to #18
(b) Eligible Alien's Name Eligible Alien's Social Security Number
Go to #18
18.
(a) Do you have any unsatisfied felony warrants for your
arrest?
You
YES
Go to (b)
NO
Go to #19
Your Spouse, if filing
YES
Go to (b)
NO
Go to #19
(b) In which State or Country was this warrant issued?
Name of State/Country
Go to (c)
Name of State/Country
Go to (c)
(c) Was the warrant satisfied?
You
YES
Go to (d)
NO
Go to #19
Your Spouse, if filing
YES
Go to (d)
NO
Go to #19
(d) Date warrant satisfied
(MM/DD/YYYY) (MM/DD/YYYY)
PART 2 - LIVING ARRANGEMENTS - The questions in this section refer to the signature date.
19.
Check the block which best describes your present living situation:
Household
Since (MM/DD/YYYY)
Go to #24
Non-Institutional Care
Since (MM/DD/YYYY)
Go to #22
Institution
Since (MM/DD/YYYY)
Go to #20
Transient or homeless
Since (MM/DD/YYYY)
Go to #37
INSTITUTION
20.
Check the block that identifies the type of institution where you currently reside, then Go to #21:
School
Hospital
Rest or Retirement Home
Nursing Home
Rehabilitation Center
Jail
Other (Specify)
21.
Give the following information about the INSTITUTION:
(a) Name of institution:
(b) Date of admission:
(c) Date you expect to be released from this institution:
Go to #37
NON-INSTITUTIONAL CARE
22.
Check the block that best describes your current residence, then Go to #23:
Foster Home Group Home Other (Specify)
✔
✔
✔
✔
06/01/2014
✔
Form SSA-8000-BK (06-2019) UF
Page 7 of 24
23.
Give the following information about your Noninstitutional Care:
(a) Name of facility where you live:
(b) Name of placing agency
Address
Telephone Number
(c) Does this agency pay for your room and board?
YES Go to #37
NO If NO, who pays?
Go to #37
HOUSEHOLD ARRANGEMENTS
24.
Check the block that describes your current residence, then Go to #25:
House
Apartment
Room (private home)
Room (commercial establishment)
Mobile Home
Houseboat
Other (Specify)
25. Do you live alone or only with your spouse? YES Go to #27 NO Go to #26
26.
(a) Give the following information about everyone who lives with you:
Name Relationship
Public
Assistance
YES NO
Sex
M F
Birthdate
mm/dd/yy
Blind or
Disabled
YES NO
If Under 22
Married
YES NO
Student
YES NO
Social Security
Number
If anyone listed is under age 22 and not married, Go to (b); otherwise, Go to #27.
✔
shelter
✔
Form SSA-8000-BK (06-2019) UF Page 8 of 24
26.
(b) Does anyone listed in 26(a) who is under age 18, OR
between ages 18-22 and a student, receive income?
YES Go to (c) NO Go to #27
(c) Child Receiving Income Source and Type Monthly Amount
$
$
$
$
$
$
27.
(a) Do you (or does anyone who lives with you) own or
rent the place where you live?
YES Go to #28 No Go to (b)
(b) Name of person who owns or rents the place where you live
Address
Telephone Number
(c) If you live alone or only with your spouse, and do not own or rent, Go to #37; otherwise, Go to #31.
28.
(a) Are you (or your living with spouse) buying or do you
own the place where you live?
YES
Go to (c)
No
If you are a child living with
your parent(s) Go to (b);
otherwise Go to #29
(b) Are your parent(s) buying or do they own the place
where you live?
YES Go to (c) NO Go to #29
(c) What is the amount and frequency of the mortgage payment?
Amount:
$
Frequency of Payment:
Go to (d)
(d) If you are a child living only with your parents, or only with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living alone or with your spouse, Go to #37;
otherwise Go to #31.
✔
✔
Form SSA-8000-BK (06-2019) UF Page 9 of 24
29.
(a) Do you (or your living with spouse) have rental liability
for the place where you live?
YES
Go to (d)
No
If you are a child living with
your parent(s) Go to (b);
otherwise Go to (c)
(b) Does your parent(s) have rental liability?
YES Go to (d) NO Go to (c)
(c) Does anyone who lives with you have rental liability for the place where you live?
YES Give name of person with rental liability:
Go to #30
NO Give name of person with home ownership:
Go to #31
(d) What is the amount and frequency of the rent payment?
Amount:
$
Frequency of Payment:
Go to #30
30.
(a) Are you (or anyone who lives with you) the parent or
child of the landlord or the landlord's spouse?
YES Go to (b) NO Go to (c)
(b) Name of person related to landlord or landlord's spouse
Relationship
Name and address of landlord (include telephone number and area code, if known):
(c) If you are a child living only with your parents, or only with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living alone or with your spouse, Go to #37.
31.
(a) Does anyone living with you contribute to the
household expenses? (NOTE: See list of household
expenses in #36)
YES Go to (b) NO
Go to #32
(b) Amount others contribute: $
Go to #32
32.
(a) Do you eat all your meals out?
YES Go to #33 NO Go to (b)
(b) Do you buy all your food separately from other
household members:
YES Go to #33 NO Go to #33
33.
Do you contribute to household expenses?
YES Average Monthly Amount: $ Go to #34 NO Go to #34
34.
(a) Do you have a loan agreement with anyone to repay
the value of your share of the household expenses?
YES Go to (b) NO Go to #34(d)
(b) Give the name, address and telephone number of the person with whom you have a loan agreement :
(c) Will the amount of this loan cover your share of the
household expenses?
YES Go to #37 NO Go to (d)
(d) If you contribute toward household expenses and you answered "NO" to both 32(a) & (b), Go To #35. If you
answered "YES" to either 32(a) or 32(b), Go to #36.
If you do not contribute toward household expenses, go to #37.
✔
✔
✔
✔
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 10 of 24
35.
(a) Is part or all of the amount in #33 just for food?
YES Give Amount: $ Go to (b) NO Go to (b)
(b) Is part or all of the amount in #33 just for shelter?
YES Give Amount: $ Go to #36 NO Go to #36
36.
What is the average monthly amount of the following household expenses:
(Show average over the past 12 months unless you have been residing at your present address less than 12
months. If so, show average for the months you have resided at your present address.)
CASH EXPENSES AVERAGE MONTHLY AMOUNT
Food (complete only if #32(a) & (b) are answered NO) $
Mortgage or Rent $
Property Insurance (if required by mortgage lender) $
Real Property Taxes $
Electricity $
Heating Fuel $
Gas $
Sewer $
Garbage Removal $
Water $
TOTAL $
Go to #37
37. (a) Does anyone who does NOT LIVE with you pay for, or provide you or your household (if applicable), any of your
food or shelter items?
YES
Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NO
Go to (b)
(b) Does anyone who does NOT LIVE with you give you, or your household (if applicable), money to pay for any of
your or your household's food or shelter items?
YES
Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NO
Go to #38
38.
(a) Has the information given in #19-37 been the same
since the first moment of the filing date month?
YES
Go to (b)
No
Explain in Remarks,
then Go to (b)
(b) Do you expect any of this information to change?
YES
Explain in Remarks,
then Go to #39
No
Go to #39
✔
✔
0.00
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 11 of 24
PART 3 - RESOURCES - The questions in this section pertain to the first moment of the filing date month.
39.
(a) Do you own or does your name appear, either alone or
with other people on any trust?
You
YES
Go to (b)
NO
Go to #40
Your Spouse, if filing
YES
Go to (b)
NO
Go to #40
(b) If you answered "YES" to (a), give the following information:
Title of the Trust
Funding type, i.e., self-
funded or third party
funded alleged
Date established
(MM/DD/YYYY)
Total alleged
value
Specific assets contained within
the trust, i.e., vehicles, homes,
bank accounts, etc.
40.
(a) Do you own, or does your name appear (alone or with
any other person's name) on the title of any vehicles
(auto, truck, motorcycle, camper, boat, etc.)?
You
YES
Go to (b)
NO
Go to #41
Your Spouse
YES
Go to (b)
NO
Go to #41
(b) Owner's Name
Description
(Year, Make & Model)
Used For
Current Market
Value
Amount Owed
$ $
$ $
$ $
$ $
41.
(a) Do you own, or does your name appear (alone or with
any other person's name) on any land, houses,
buildings, real property, property in foreign country,
equipment, mineral rights, items in a safe deposit box,
assets set aside for emergencies or heirs, or any other
property of any kind that has not been shown
anywhere else on the application
You
YES
Go to (b)
NO
Go to #42
Your Spouse
YES
Go to (b)
NO
Go to #42
(b) Describe the property (including size, address, and how it is used. If the property is not used now, when was it
last used? Do you plan to use the property in the future?
Item #1
Item #2
Owner's Name
Estimated
Current Market
Value
Owed on Item
$ $
$ $
$ $
$ $
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 12 of 24
42.
(a) Do you own, or does your name appear on (either
alone or with any other person's name) any of the
following items?
You
YES NO
Your Spouse
YES NO
Cash at home, with you, or anywhere else
Financial Institution Accounts
Achieving a Better Life Experience (ABLE)
Checking
Savings
Credit Union
Christmas Club
Time Deposits/Certificates of Deposit
Individual Indian Money Account
Other (Including IRAs and Keough Accounts)
(b) If all the items in #42(a) are answered "NO", Go to #42(c). For any "YES" answer, give the following information:
Owner's Name Name of Item Value
Name & Address of Bank or
Other Organization
Identifying
Number
$
$
$
$
(c) Do you give us permission to obtain any financial
records from any financial institution?
You
YES
Go to #43
NO
Go to #43
Your Spouse, if filing
YES
Go to #43
NO
Go to #43
43.
(a) Do you own or does your name appear on any of the
following items:
You
YES NO
Your Spouse
YES NO
Stocks or Mutual Funds
Bonds (Including U.S. Savings Bonds)
Promissory Notes
Other items that can be turned into cash
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 13 of 24
43.
(b) If all the items in #43(a) are answered "NO", Go to #44. For any "YES" answer, give the following information:
Owner's Name Name of Item Value
Name & Address of Bank or
Other Organization
Identifying
Number
$
$
$
$
44.
(a) Do you own or are you buying any life insurance
policies?
You
YES
Go to (b)
NO
Go to #45
Your Spouse
YES
Go to (b)
NO
Go to #45
(b) Owner's Name Name of Insured
Name & Address of
Insurance Company
Policy Number
Policy (#1)
Policy (#2)
Policy (#3)
Face Value Cash Surrender Value Date of Purchase
Dividends
YES NO
Accumu-
lations
YES NO
Policy (#1)
Policy (#2)
Policy (#3)
(c) Loans Against Policy?
YES
Policy Number:
Amount: $
NO
Go to #45
45.
(a) Have you or your spouse acquired any assets since
the first moment of the filing date month?
YES Go to (b) NO Go to (c)
(b) Explain:
✔
✔
Form SSA-8000-BK (06-2019) UF Page 14 of 24
45.
(c) Has there been any increase or decrease in the value
of you or your spouse's resources since the first
moment of the filing date month?
YES Go to (d) NO Go to #46
(d) Explain:
46.
(a) Do you (either alone or jointly with any other person)
own any:
You
YES NO
Your Spouse
YES NO
Life estates or ownership interest in an unprobated
estate?
Items acquired or held for their value as an investment?
(b) Give the following information for any "Yes" answer in #46(a); otherwise, Go to #47.
Owner's Name Name of Item Value Amount Owed
Name & Address of Bank or
Other Organization
$ $
$ $
$ $
$ $
47.
(a) Do you have any assets set aside for burial
expenses such as burial contracts, trusts,
agreements, or anything else you intend for your
burial expenses? Include any items mentioned in
#39, #41-45, and #49.
You
YES
Go to (b)
NO
Go to #48
Your Spouse
YES
Go to (b)
NO
Go to #48
(b) DESCRIPTION (Where appropriate, give name
& address of organization and account/ policy
number.)
Value
When Set Aside
(MM/DD/YYYY)
Owner's Name
For Whose Burial Is Item Irrevocable?
Will Interest Earned or Appreciation in
Value Remain in the Burial Fund?
Item (#1) $
Item (#1)
YES NO
YES
Go to #48
NO
Explain in (c)
Item (#2)
$
Item (#2)
YES NO
YES
Go to #48
NO
Explain in (c)
(c) Explanation
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 15 of 24
48.
(a) Do you own any cemetery lots, crypts, caskets, vaults,
urns, mausoleums, or other repositories for burial or
any headstones or markers?
You
YES
Go to (b)
NO
Go to #49
Your Spouse
YES
Go to (b)
NO
Go to #49
(b) Owner's Name Description For Whose Burial
Relationship to You or
Your Spouse
Current Market
Value
$
$
$
Go to #49
49.
(a) 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 the filing date
month?
You
YES
NO
Go to (b)
Your Spouse
YES
NO
Go to (b)
(b) If you co-owned any money or property with another
person(s), did you or any co-owner sell, transfer, or
give away any co-owned money or property within the
36 months prior to the filing date month?
YES
NO
YES
NO
IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #50.
(c) Owner's/Co-Owner's Name Description of Property Date of Disposal
Name and Address of
Purchaser or Recipient
Relationship to Owner
Value of Property and/or
Amount of Cash Gift
Sales Price or Other Consideration
Are Other Consideration
or Proceeds Expected?
Explain.
Do You Still Own Part of
the Property?
Sold on Open Market? Given Away?
Traded for Goods/
Services?
Item (#1)
Item (#1)
Item (#1)
Item (#1) YES NO YES NO YES NO
Item (#2)
Item (#2)
Item (#2)
Item (#2)
YES
NO
YES
NO
YES
NO
Item (#3)
Item (#3)
Item (#3)
Item (#3) YES NO YES NO YES NO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 16 of 24
PART 4 - INCOME
50.
(a) Since the first moment of the filing date month, have
you (or your spouse) received or do you (or your
spouse) expect to receive income in the next 14
months from any of the following sources?
You
YES NO
Your Spouse
YES NO
State or Local Assistance Based on Need
Refugee Cash Assistance
Temporary Assistance for Needy Families
General Assistance from the Bureau of Indian Affairs
Disaster Relief
Veteran Benefits Based on Need (Paid Directly or
Indirectly as a Dependent)
Veteran Payments Not Based on Need (Paid Directly or
Indirectly as a Dependent)
Other Income Based on Need
Social Security
Black Lung
Railroad Retirement Board Benefits
Office of Personnel Management (Civil Service)
Pension (Foreign Military, State, Local, Private, Union,
Retirement or Disability)
Military Special Pay or Allowance
Unemployment Compensation
Workers' Compensation
State Disability
Insurance or Annuity Payments
Dividends/Royalties
Rental/Lease Income Not from a Trade or Business
Alimony
Child Support
Other Bureau of Indian Affairs Income
Gambling/Lottery Winnings
Other Income or Support
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 17 of 24
50.
(b) Give the following information for any block checked YES in #50(a); otherwise, Go to #51
Person
Receiving
Income
Type of Income
Amount
Received
Frequency of
Payment
Date
Expected or
Received
Source (Name, Address of
Person,Bank,
Organization, or Company)
Identifying
Number
$
$
$
IF YOU EVER RECEIVED SSI BEFORE, GO TO #51; OTHERWISE GO TO #52.
51.
Are any overpayments being collected from benefits you
receive from the Social Security Administration, Railroad
Retirement Board, Office of Personnel Management,
Veterans' Affairs, Military Pensions, Military Special Pay
Allowances, Black Lung, Workers' Compensation, or State
Disability or Unemployment Benefits?
You
YES
Explain in
Remarks,
then Go to
#52
NO
Go to #52
Your Spouse
YES
Explain in
Remarks,
then Go to
#52
NO
Go to #52
52.
Since the first moment of the filing date month, have you
received or do you expect to receive any meals or other
gifts which are not cash?
YES
Explain in
Remarks,
then Go to
#53
NO
Go to #53
YES
Explain in
Remarks,
then Go to
#53
NO
Go to #53
53.
(a) Have you (or your spouse) received wages or sick pay
since the first moment of the filing date month through
the current month?
YES
Go to (b)
NO
Go to (e)
YES
Go to (b)
NO
Go to (e)
(b) Name and Address of Employer (include telephone number and area code, if known)
You
Go to (c)
Your Spouse
Go to (c)
(c)
Date last worked
(MM/DD/YYYY)
Date last paid
(MM/DD/YYYY)
Date next paid
(MM/DD/YYYY)
You
Your Spouse
(d) Total monthly wages received (before any deductions)
Your Amount
$
Your Spouse's Amount
$
(e) Do you (or your spouse) expect to receive any wages
in the next 14 months?
You
YES
Go to (f)
NO
Go to #54
Your Spouse
YES
Go to (f)
NO
Go to #54
✔
✔
✔
✔
Form SSA-8000-BK (06-2019) UF Page 18 of 24
53.
(f) Name and address of employer if different from #53(b) (include telephone number, if known)
You
Your Spouse
(g) Give the following information:
Rate of Pay
Amount Worked Per
Pay Period
How Often Paid
Pay Day or
Date Paid
Date Last Paid
(MM/DD/YYYY)
You
Your
Spouse
(h) Do you expect any change in wage information
provided in #53(g)
You
YES
Go to (i)
NO
Go to #54
Your Spouse
YES
Go to (i)
NO
Go to #54
(i) Explain Change:
You
Your Spouse
54.
(a) Have you been self-employed at any time since the
beginning of the taxable year in which the filing date
month occurs or do you expect to be self-employed in
the current taxable year?
You
YES
Go to (b)
NO
Go to #55
Your Spouse
YES
Go to (b)
NO
Go to #55
(b) Give the following information; then Go to #55
Date(s) Self-Employed Type of Business Last Year's:
Gross Income
$
Last Year's:
Net Profit
$
Last Year's:
Net Loss
$
Date(s) Self-Employed Type of Business This Year's:
Gross Income
$
This Year's:
Net Profit
$
This Year's:
Net Loss
$
55.
If you or your spouse are blind or disabled, do you have
any special expenses that you paid which are necessary
for you to work?
You
YES
Explain in
Remarks,
then Go to
#56
NO
Go to #56
Your Spouse
YES
Explain in
Remarks,
then Go to
#56
NO
Go to #56
✔
✔
Form SSA-8000-BK (06-2019) UF Page 19 of 24
56.
(a) Does your spouse/parent who lives with you have to
pay court-ordered support?
YES Go to (b) NO Go to NOTE
(b) Give amount and frequency of court-ordered support payment.
Amount:
$
Frequency of Payment:
Go to (c)
(c) Give the following information about the person who receives these payments:
Name:
Address:
NOTE: IF YOU ARE FILING AS A CHILD AND YOU ARE EMPLOYED OR AGE 18 - 22 (WHETHER EMPLOYED
OR NOT), GO TO #57; OTHERWISE, GO TO #58.
57.
(a) Have you attended school regularly since the filing
date month?
YES Go to (d) NO Go to (b)
(b) Have you been out of school for more than 4 calendar
months?
YES Go to (c) NO Go to (c)
(c) Do you plan to attend school regularly during the next
4 months?
YES Explain absence in
Remarks and Go to (d)
NO Go to #58
(d) Name of School Name of School Contact
Phone Number
Dates of Attendance
From To
Hours Attending or
Planning to Attend
Course of
Study
PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/MEDICAL
ASSISTANCE/OTHER BENEFITS
58.
(a) Are you currently receiving SNAP benefits (formerly
food stamps)?
You
YES
Go to (b)
NO
Go to (c)
Your Spouse, if filing
YES
Go to (b)
NO
Go to (c)
(b) Have you received a recertification notice within the
past 30 days?
YES
Go to (e)
NO
Go to #59
YES
Go to (e)
NO
Go to #59
(c) Have you filed for SNAP in the last 60 days?
YES
Go to (d)
NO
Go to (e)
YES
Go to (d)
NO
Go to (e)
(d) Have you received an unfavorable decision?
YES
Go to (e)
NO
Go to #59
YES
Go to (e)
NO
Go to #59
(e) If everyone in the household receives or is applying for SSI, Go to (f); otherwise Go to #59.
(f) May I take your SNAP application today?
YES
Go to #59
NO
Explain in (g)
YES
Go to #59
NO
Explain in (g)
(g) Explanation:
✔
✔
✔
✔
Any Town High School
Brenda Clifford, Special Education Teacher
123-456-1234
2014
2017
4-5
General
Studies
✔
✔
✔
✔
✔
Tiffany is under the age of 18 and currently living a shelter where food is provided.
Form SSA-8000-BK (06-2019) UF Page 20 of 24
59.
You may be eligible for Medicaid. However, you must help your State identify other sources that pay for medical
care. Also, you must give information to help the State get medical support for any child(ren) who is your legal
responsibility. This includes information to help the State determine who a child's parent is. If you want Medicaid,
you must agree to allow your State to seek payments from sources, such as insurance companies, that are available
to pay for your medical care. This includes payments for medical care for you or any person who receives Medicaid
and is your legal responsibility. The State cannot provide you Medicaid if you do not agree to this Medicaid
requirement. If you need further information, you may contact your Medicaid Agency.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to (b).
(a) Do you agree to assign your rights (or the rights of
anyone for whom you can legally assign rights) to
payments for medical support and other medical care
to the State Medicaid agency?
You
YES
Go to (b)
NO
Go to #60
Your Spouse, if filing
YES
Go to (b)
NO
Go to #60
(b) Do you, your spouse, parent or stepparent have any
private, group, or governmental health insurance that
pays the cost of your medical care? (Do not include
Medicare or Medicaid.)
YES
Go to (c)
NO
Go to (c)
YES
Go to (c)
NO
Go to (c)
(c) Do you have any unpaid medical expenses for the 3
months prior to the filing date month?
YES
Go to #60
NO
Go to #60
YES
Go to #60
NO
Go to #60
60.
(a) Have you ever worked under the U.S. Social Security
System?
YES Go to (b) NO Go to (b)
(b) Have you, your spouse, or a former spouse (or parent
if you are filing as a child) ever:
You
YES NO
Your Spouse/
Parent
YES NO
Filed for
Benefits
YES NO
Worked for a railroad
Been in military service
Worked for the Federal Government
Worked for a State or Local Government
Worked for an employer with a pension plan
Belonged to union with a pension plan
Worked under a Social Security system or pension plan of
a country other than the United States?
(c) Explain and include dates for any "Yes" answer given in #14 or #60(a); otherwise Go to #61.
You
Your Spouse, if filing/Your Parent, if filing as a child:
PART 6 - MISCELLANEOUS - (Answer #61 ONLY IF YOU ARE APPLYING ON BEHALF OF SOMEONE ELSE:
OTHERWISE GO TO #62.
61. (a) Name of Person/Agency Requesting
Benefits.
Relationship to Claimant Your Social Security Number
(or EIN)
(b) If SSA determines that the claimant needs help
managing benefits, do you wish to be selected
representative payee?
YES
NO
(Explain in Remarks)
(c) Have you ever served as a representative payee for a
Social Security beneficiary or SSI claimant?
YES
NO
Go to #62
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Maria Rivera XYZ Community Mental Health Center
SOCIAL WORKER
✔
✔
Form SSA-8000-BK (06-2019) UF Page 21 of 24
PART 7 - REMARKS - (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.)
SOAR Caseworker is Maria Rivera with XYZ Community Mental Health Center , (111) 222-3333
(Q 51) Tiffany receives free meals from Some City Children's Shelter.
Form SSA-8000-BK (06-2019) UF Page 22 of 24
PART 8 - IMPORTANT INFORMATION AND SIGNATURES
62.
IMPORTANT INFORMATION - PLEASE READ CAREFULLY
• Failure to report any change within 10 days after the end of the month in which the change occurs could result in a
penalty deduction.
• 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.
• We have asked you for permission to obtain, from any financial institution, any financial record about you that is
held by the institution. We will ask financial institutions for this information whenever we think it is needed to
decide if you are eligible or if you continue to be eligible for SSI benefits. Once authorized, our permission to
contact financial institutions remains in effect until one of the following occurs:
(1) you or your spouse notify us 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) we no longer consider your spouse's income and resources 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 we may deny your
claim or stop your payments.
63.
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 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 Signature (First name, middle initial, last name) (Sign in ink.) Date (MM/DD/YYYY)
Telephone Number(s) where we can
contact you during the day:
Spouse's Signature (Sign only if applying for payments.) (First name, middle initial, last name) (Sign in ink.)
64. If you are blind or visually impaired, check the type of mail you want to receive from us.
Standard notice First Class
Standard notice First-Class with a follow-up phone call
Standard notice & data CD by First-Class
Standard notice Certified
Standard & Braille notices by First-Class
Standard & large print notices
Standard notice & audio CD
65.
WITNESS
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 address.
1. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)
2. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)
2/06/2018
111 222 3333
Form SSA-8000-BK (06-2019) UF Page 23 of 24
RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOME
Name Social Security Number Date
Name Social Security Number Date
If you have a question or something to report call: Social Security Office you may visit or mail your request to:
For general information about Social Security, visit our website at www.socialsecurity.gov on the Internet.
We will process your application for Supplemental Security Income as quickly as possible. If you have trouble getting any
information or records we have asked for, please contact us and we will help you.
You should hear from us within _____ days after you have given us all the information we requested. Some claims may
take longer if additional information is needed. If you do not get a check or notice of determination within that time,
please get in touch with us.
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate
and timely decision on a claim for Supplemental Security Income (SSI) or could result in the loss of benefits.
We will use the information to determine SSI eligibility and to calculate SSI payment amounts. We may also share your
information for the following purposes, called routine uses:
• To third party contacts, where necessary, to establish or verify information provided by representative payees or
payee applicants; and
• To State agencies, to enable them to assist in the effective and efficient administration of the SSI program.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared
with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or
delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled
Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, and 60-0103, entitled
SSI Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional
information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy
.
Paperwork Reduction Act Statement
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 40 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
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). You may send comments on our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income (SSI) check is based on the information told to us. You must tell Social
Security every time there is a change-while we process your application AND if you start receiving SSI. Remember, a
change may make the SSI monthly payment bigger or smaller. Report changes in income of your ineligible spouse or
child who lives with you or your sponsor or sponsor's spouse, if you are an alien. You must also report changes in the
things of value that these people own. You must also report changes in income, school attendance and marital status of
ineligible children who live with you. You must tell us about any change within 10 days after the month it happens. If you
do not report changes, we may have to take as much as $25, $50, or $100 out of future checks.
HOW TO REPORT
You may make your reports:
• By telephone at the telephone number shown above or call us toll free at 1-800-772-1213 (TTY 1-800-325-0778)
or
• In person or
• By mail at the address shown above.
Form SSA-8000-BK (06-2019) UF Page 24 of 24
CHANGES TO REPORT
WHERE YOU LIVE - You must report to Social Security if:
• You move.
• You (or your spouse) leave your household for a
calendar month or longer. (For example, you enter a
hospital or visit a relative.)
• You are admitted to (for a calendar month or longer),
or released from, a hospital or nursing home, jail,
prison, or other correctional facility or other institution.
• You leave the United States for 30 consecutive days.
• You are no longer a legal resident of the United
States
HOW YOU LIVE - You must report to Social Security:
• If anyone moves into or out of your household.
• If the amount of money you pay toward household
expenses changes.
• Births and deaths of any people with whom you live.
• Your spouse or former spouse dies.
• Your marital status changes:
- You get married, separated, divorced, or your
marriage is annulled.
- You begin living with someone as a married couple.
INCOME - You must report to Social Security if you, your spouse/your parent(s):
• Start to receive money (or checks or any other type
of payment) from someone or someplace.
• Have a change in the amount of money you receive.
• Begin to receive child support payments or those
payments go up or down.
• Win money from gambling or a lottery.
• Start work or stop work.
• Earn more or less money. (Keep all paystubs and
provide them to SSA when requested.)
• Become eligible for benefits other than SSI.
HELP YOU GET FROM OTHERS - You must report to Social Security if:
• The amount of help (money or food, or payment of
household expenses) you receive goes up or down.
• Someone stops helping you.
• Someone starts helping you.
THINGS OF VALUE THAT YOU OWN - You must report to Social Security if:
• The value of things that you own goes over $2000
when you add them all together ($3000 if you are
married and live with your spouse).
• You sell or give any thing of value away.
• 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.
IF YOU ARE THE PARENT, STEPPARENT, OR REPRESENTATIVE PAYEE FOR A CHILD UNDER 18 - A report
to Social Security must be made if:
• There is a change in any income the child, his or her
parent(s), stepparent, or brother(s) or sister(s) receive.
• There is a change in the student status of the child's
brother(s) or sister(s).
• There is a change in his or her parents' or stepparents'
marriage, a change in value of anything they own, or a
change in their residence.
YOU ARE UNMARRIED AND UNDER AGE 22 - A report to Social Security must be made if:
• You start or stop school • You get married or divorced • You start or stop working
YOUR IMMIGRATION STATUS CHANGES
You must report any changes to Social Security.
YOU ARE SELECTED AS A REPRESENTATIVE PAYEE - You must report to Social Security if:
• The person for whom you receive SSI checks has
any 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
that person's representative payee.
FELONY OR ARREST WARRANT - You must report to Social Security if you have a felony or arrest warrant
for:
• Escape from custody • Flight to avoid prosecution or confinement, or
• Flight-Escape
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