Fillable Form SSA-8001-BK (09-2019) UF: Security Administration, and where (SAMHSA)

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Form SSA-8001-BK (09-2019) UF: Security Administration, and where (SAMHSA)

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Form SSA-8001-BK (09-2019) UF
Discontinue Prior Editions
Social Security Administration
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
(Deferred or Abbreviated)
Page 1 of 12
OMB No. 0960-0444
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
DEFERRED ABAP
SNAP-
SSA/APP
SNAP-
REFERRED
Filing Date (MM/DD/YYYY)
Receipt Protective
Preferred Language:
Written:
Spoken:
TYPE OF CLAIM
Individual
Individual with
Ineligible Spouse
Couple Child
Child with
Parent(s)
PART 1 - BASIC ELIGIBILITY - Answer the questions below beginning with the first moment of the filing date month.
1. First Name, Middle Initial, Last Name
2. Sex
Male
Female
3. Birthdate
(MM/DD/YYYY)
4. Social Security Number
5. If filing as spouse or couple (a) Spouse's Name(s)
6(a). Sex
Male
Female
7(a). Birthdate
(MM/DD/YYYY)
8 (a). Social Security Number(s)
If filing for child (b) Parent 1's Name(s)
6(b). Sex
Male
Female
7(b). Birthdate
(MM/DD/YYYY)
8 (b). Social Security Number(s)
If filing for child (c) Parent 2's Name(s)
6(c). Sex
Male
Female
7(c). Birthdate
(MM/DD/YYYY)
8 (c). Social Security Number(s)
8(d). Are you married?
YES, complete (e) and (f) NO, Go to (g)
(e) Date of Marriage
(MM/DD/YYYY)
(f). Are you and your spouse living together?
YES NO If no, date you began living apart
(g). Are you and another person living together in the same household and presenting to others or the community as a
married couple?
YES, provide the date holding out began (MM/DD/YYYY) . Go to (h)*.
NO Go to #9.
*(h) 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-8001-BK (09-2019) UF Page 2 of 12
9. Other Name(s) and Social Security Number(s) you or your spouse used. If filing for child benefits go to (c) and (d).
(a) Your Other Name(s) (including Name at Birth) Social Security Number
(b) Spouse's Other Name(s) (including Name at Birth) Social Security Number
(c) Parent 1's Other Name(s) (including Name at Birth) Social Security Number
(d) Parent 2's Other Name(s) (including Name at Birth) Social Security Number
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 are filing for yourself, go to (a); if you are filing for a child, go to (e).
(a) Are you unable to work or is your work limited
because of illnesses, injuries, or conditions?
You
YES
Go to (b)
NO
Go to #13
Your Spouse, if filing
YES
Go to (b)
NO
Go to #13
(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?
YES NO
Go to (d)
YES NO
Go to (d)
(d) If you were unable to work because of illnesses, injuries, or
conditions before age 22, do you have a parent or stepparent
who is age 62 or older, unable to work because of illnesses,
injuries, or conditions, or deceased?
YES
Provide name(s) and Social
Security Number(s) in Remarks
Go to #13
NO
Go to #13
(e) When did the child become disabled? (MM/DD/YYYY)
Go to (f)
(f) Is the child blind or does he or she have low vision even with
glasses or contacts?
YES
Go to (g)
NO
Go to (g)
(g) Does the child have a parent or stepparent who is 62 or older,
unable to work because of illnesses, injuries, or conditions, or
deceased?
YES
Provide name(s) and Social
Security Number(s) in Remarks
Go to #13
NO
Go to #13
13. If you (and your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a).
(a) Are you a naturalized United States citizen?
You
YES
Go to #17
NO
Go to (b)
Your Spouse, if filing
YES
Go to #17
NO
Go to (b)
(b) Are you an American Indian born outside the
United States?
YES
Go to (c)
NO
Go to (d)
YES
Go to (c)
NO
Go to (d)
Go to (c) Go to (c)
Form SSA-8001-BK (09-2019) UF Page 3 of 12
13. (c) Check the block that shows your American Indian status.
You Your Spouse, if filing
American Indian born in Canada
Go to #17
American Indian born in Canada
Go to #17
Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17
Member of a Federally recognized Indian Tribe;
Name of Tribe:
Go to #17
Other American Indian
Explain in Remarks, then Go to (d)
Other American Indian
Explain in Remarks, then Go to (d)
(d) Check the block below that shows your current immigration status.
You Your Spouse, if filing
Amerasian Immigrant
Go to #14
Amerasian Immigrant
Go to #14
Asylee
Date status granted (MM/DD/YYYY):
Go to #16
Asylee
Date status granted (MM/DD/YYYY):
Go to #16
Conditional Entrant
Date status granted (MM/DD/YYYY):
Go to #16
Conditional Entrant
Date status granted (MM/DD/YYYY):
Go to #16
Cuban/Haitian Entrant
Go to #16
Cuban/Haitian Entrant
Go to #16
Deportation/Removal Withheld
Date (MM/DD/YYYY):
Go to #16
Deportation/Removal Withheld
Date (MM/DD/YYYY):
Go to #16
Lawful Permanent Resident
Go to #14
Lawful Permanent Resident
Go to #14
Parolee for One Year
Go to #16
Parolee for One Year
Go to #16
Refugee
Date of entry (MM/DD/YYYY):
Go to #16
Refugee
Date of entry (MM/DD/YYYY):
Go to #16
Unknown/Other
Explain in Remarks, then Go to (e)
Unknown/Other
Explain in Remarks, then Go to (e)
(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United States citizen, or a
lawfully admitted permanent resident, Go to #15; otherwise, Go to #17.
Form SSA-8001-BK (09-2019) UF Page 4 of 12
14. (a) Date of admission:
You
(MM/DD/YYYY)
Your Spouse, if filing
(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:
Name Address Phone Number
(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?
You
(MM/DD/YYYY)
From:
To:
Your Spouse, if filing
(MM/DD/YYYY)
From:
To:
(e) If filing as an adult, did your parents ever work in
the United States before you were 18?
YES
Go to (f)
NO
Go to #16
YES
Go to (f)
NO
Go to #16
(f) Name and Social Security Number of parent(s) who worked.
Name Social Security Number
Name Social Security Number
15. (a) Have you, your child, or your parent, been
subjected to battery or extreme cruelty while in
the United States?
You Your Spouse, if filing
YES
Go to (b)
NO
Go to #17
YES
Go to (b)
NO
Go to #17
(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 #16
NO
Go to #17
YES
Go to #16
NO
Go to #17
16. Are you, your spouse, or parent an active duty
member or a veteran of the armed forces of the
United States?
YES
Explain in
Remarks, then
Go to #17
NO
Go to #17
YES
Explain in
Remarks, then
Go to #17
NO
Go to #17
17. (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 #18
YES
Go to (c)
NO
Go to #18
(c) Give the date(s) of residence outside the United
States.
Date
Left:
(MM/DD/YYYY)
Date
Returned:
(MM/DD/YYYY)
Date
Left:
(MM/DD/YYYY)
Date
Returned:
(MM/DD/YYYY)
Form SSA-8001-BK (09-2019) UF Page 5 of 12
18. (a) Have you been outside the United States (the 50
States, District of Columbia and Northern
Mariana Islands) 30 days prior to the filing date?
You Your Spouse, if filing
YES
Go to (b)
NO
Go to #19
YES
Go to (b)
NO
Go to #19
(b) Give the date (MM/DD/YYYY) you left the
United States and the date you returned to the
United States.
Date
Left:
(MM/DD/YYYY)
Date
Returned:
(MM/DD/YYYY)
Date
Left:
(MM/DD/YYYY)
Date
Returned:
(MM/DD/YYYY)
19. Claimant's Mailing Address (Number & Street, Apt. No., P.O. Box, or Rural Route)
City and State (U.S.) ZIP Code Name of County in which you live Telephone Number
State/Province/Region (Foreign)
Postal Code Country
20. 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
21. (a) Do you have any felony warrants for escape
from custody, flight to avoid prosecution or
confinement, or flight escape?
You Your Spouse, if filing
YES
Go to (b)
NO
Go to #22
YES
Go to (b)
NO
Go to #22
(b) In which State or country was the warrant
issued?
Name of State/Country
Go to (c)
Name of State/Country
Go to (c)
(c) Was the warrant satisfied?
YES
Go to (d)
NO
Go to #22
YES
Go to (d)
NO
Go to #22
(d) Date warrant satisfied:
(MM/DD/YYYY)
(MM/DD/YYYY)
PART 2 - LIVING ARRANGEMENT (Use "Remarks" to explain any change between the first moment of the filing date
month and today.)
22. Claimant's Residence Address (Number & Street, Apt. No., P.O. Box, or Rural Route)
City and State (U.S.)
ZIP Code Name of County in which you live
State/Province/Region (Foreign)
Postal Code Country
Form SSA-8001-BK (09-2019) UF Page 6 of 12
23. (a) Mark the box that describes where you live.
House, apartment, mobile home, houseboat
Room in commercial establishment Institution (hospital, rehabilitation center, prison, or school)
Room in private home Transient or homeless
Noninstitution (rest home, retirement home, foster home, or
group home)
(b) Date you began living there: (MM/DD/YYYY)
24. 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.
Alone Spouse/Parents and/or Children Other People
25. 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.
Yes No
Description of Items
Marked Yes
Co-owned
With Others
Yes No
Dollar Value
You Own
Dollar Value
Spouse or
Parents Own
(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. $ $
(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. $ $
(n) Other Resource. $ $
26. Are there any assets set aside to meet burial
expenses for you or your spouse/parent(s)? (If"Yes"
describe the item in "Remarks".
Your answer
YES NO
Spouse's answer YES NO
Parent 1's answer
YES NO
Parent 2's answer YES NO
PART 3 - RESOURCES (Show resources as of the first moment of the filing date month. Use "Remarks" to explain any
changes.)
Form SSA-8001-BK (09-2019) UF Page 7 of 12
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 #28.
(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
Sale Price or Other Consideration
Are Other Considerations 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
YES NO
Item #1 YES NO YES NO YES NO
Item #2
Item #2
$
Item #2
YES NO
Item #2 YES NO YES NO YES NO
Item #3
Item #3
$
Item #3
YES NO
Item #3 YES NO YES NO YES NO
28. Do you give us permission to obtain any financial
records from any financial institution?
You Your Spouse, if filing
YES NO YES NO
PART 4 - INCOME (List all income received since the first moment of the filing date month or expected in the next 3
months.) Include you, your spouse/parents.
27. (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 filing date
month?
You
Your Spouse, if filing
YES NO YES NO
Form SSA-8001-BK (09-2019) UF Page 8 of 12
29. List cash, checks, and direct payment to bank accounts you (your spouse/parents) 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.
Person Receiving Income Type of Income Amount
Frequency
Received
Date Last Paid Source of Income
$
$
$
Also, note here if anyone pays any bills for you directly or gives you money to pay them.
30. (a) Does your spouse/parent pay court ordered child support?
YES
Go to (b)
NO
Go to #31
(b) Give the amount and frequency of payment:
$
PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/
MEDICAL ASSISTANCE
31. (a) Are you currently receiving SNAP benefits
(formerly food stamps)?
You
Your Spouse, if filing
YES
Go to (b)
NO
Go to (c)
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 #32
YES
Go to (e)
NO
Go to #32
(c) Have you filed for SNAP benefits 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 a favorable decision?
YES
Go to #32
NO
Go to (e)
YES
Go to #32
NO
Go to (e)
(e) May I take your SNAP application today?
YES
Go to #32
NO
Explain in (f)
YES
Go to #32
NO
Explain in (f)
(f) Explanation:
32. 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
Your Spouse, if filing
YES
Go to (b)
NO
Go to #33
YES
Go to (b)
NO
Go to #33
Form SSA-8001-BK (09-2019) UF Page 9 of 12
32. (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.)
You
Your Spouse, if filing
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 #33
NO
Go to #33
YES
Go to #33
NO
Go to #33
PART 6 - MISCELLANEOUS
ANSWER #33(a) ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE;
OTHERWISE GO TO #33(b).
33. (a) Name of Person Requesting Benefits
Relationship to Claimant Your Social Security Number
(b) Have you ever served as representative payee for a Social
Security beneficiary or SSI claimant?
YES
Go to #34
NO
Go to #34
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.)
Form SSA-8001-BK (09-2019) UF Page 10 of 12
PART 8 - IMPORTANT INFORMATION - PLEASE READ CAREFULLY
34. 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.
PART 9 - SIGNATURES
35. 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.
36. Your Signature (First name, middle initial, last name) (Write in ink.) Date (MM/DD/YYYY)
37. Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)
WITNESSES
38. 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)
Form SSA-8001-BK (09-2019) UF Page 11 of 12
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 write to:
Your application for Supplemental Security Income will be processed as quickly as possible. You should hear from us within
days. If you do not hear from us within that time, please get in touch with us in person, by mail, or call us at the telephone number
shown at the top of this page.
We may need more information before we can decide whether or not you are eligible for SSI payments. If we need more
information, we will contact you. In the meantime, if you move or change your mailing address, you (or someone for you) should
report the change to the office shown at the top of this page.
You (or someone for you) must let us know if your immigration status changes.
Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. You could lose some
SSI payments if you do not let us know right away.
Always give your Social Security Number when writing or telephoning about your claim. If you have any questions about your
claim, we will be glad to help you.
Form SSA-8001-BK (09-2019) UF Page 12 of 12
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 this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any
claim filed.
We will use the information to determine eligibility for Supplemental Security Income (SSI) payments. We may also
share your information for the following purposes, called routine uses:
• To specified business and other community members and Federal, State, and local agencies for verification of
eligibility for benefits under section 1631(e) of the Act; 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 Systems, as published in the Federal Register (FR) on April 01, 2003, at 68FR 15784, and 60-0103,
entitled Supplemental Security Income 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 of our SORNs, is available on our website at
www.ssa.gov/privacy.
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 19-20 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.
Paperwork Reduction Act Statement
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Completed 5 January 2022

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