Statement for Determining Continuing Eligibility for Supplemental Security Income Payment--Adult/Statement for Determining Continuing Eligibility for Supplemental Security Income.....

Social Security Administration
IMPORTANT FACTS ABOUT SSI
Things You Need
To Report To Us

You must report changes to us that affect your SSI. The easiest way to report a
change is to call us toll free, at 1-800-772-1213. If any changes that we list below
apply to you, call us right away.
• You move or anyone else moves into or out of the place where you live. Also
report births and deaths of people who live with you.
• You get married, divorced, separated, have your marriage annulled, or your
spouse dies.
• You (or your spouse or your parents(s) living with you) start working or the
amount of money you (or your spouse or parent(s) living with you) earn goes up
or down.
• Someone starts or stops helping you pay your bills.
The amount of other checks or income you (or your spouse or your parent(s)
living with you) receive goes up or down (pensions, worker's compensation or
unemployment insurance, etc.)
• The value of your resources (things you or your parent(s) own) when added
together goes over $2,000 ($3,000 if you are married and living with your
spouse).
• You (or your spouse living with you) sell, transfer title, dispose of or give away
any money or property, including money or property in a foreign country.
You (or your spouse living with you) leave the place where you live for a full
calendar month. For example: You enter a hospital, nursing home, jail, or visit a
relative and stay throughout a full calendar month.
• A calendar month is all the days in a month. For example, if you were admitted
to a hospital on November 23 rd and were discharged on January 4 th , the full
calendar month is December.
• You are released from a hospital, nursing home, jail, or other institution.
• You leave the U.S. for more than 30 days in a row. (The U.S. includes the 50
States, the District of Columbia, and the Northern Mariana Islands.)
• You are getting SSI because you are disabled or blind and your health problem
Improves.

•

If you have any unsatisfied felony warrants for your arrest or if you have any

unsatisfied Federal or State warrants for violating a condition of parole or

probation.

Form SSA-3989-0CR-SM-FST-FAC (7-2006)

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Important Facts
About Food
Stamps

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

Facts About
Computer
Matching
Programs

We may 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.

Important Facts
about Resources

•

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.

WHAT ARE RESOURCES FOR SSI?

Resources are things that you (or your spouse or your parent(s) living with you) own

and can use to get food or shelter. Resources can include:

• Cash;
•

Real Property, such as a house or land;

•

Personal property such as a car, bank accounts, or investments like stocks, bonds
or life insurance.

WHAT HAPPENS WHEN YOU GIVE AWAY OR SELL A

RESOURCE?

You may not be able to get SSI for a period of time if you (or your spouse or your

parent(s) living with you) or another person gives away your resource or sells it for

less than it is worth. This period may be up to 36 months, depending on how much

the resource was worth and how much you got for it.

You also may not be able to get SSI if you (or your spouse or your parent(s) living

with you) or someone else puts resources or other things you own or have a right to in

a trust.

REPORTING TO YOUR STATE MEDICAID AGENCY

SSA uses information about your resources to decide if you can get SSI. SSA also

gives your State Medicaid agency information that we have about things you have

given away or sold for less than they are worth. Your State Medicaid agency uses this

information to decide if you can get Medicaid.

IF YOU HAVE OUESTIONS ABOUT SSI

If you have questions about SSI, including how resources can affect your eligibility,

you can contact your local Social Security office or call us toll free at 1-800-772­

1213. We will answer your questions about how resources affect your SSI.

orm SSA-3989-0CR-SM-FST-FAC (7-2006)

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Important
Information
About Medicaid

If you have Medicaid or you are filing for Medicaid, the following information about

assets is important to you.

WHAT ARE ASSETS FOR MEDICAID?

Your State looks at all your assets when it decides if you can get Medicaid. Your

assets can include:

Money you or your spouse get from wages or self-employment;
Any other money you or your spouse get, such as money from Social Security or
friends or relatives;
Any free food or shelter you or your spouse get;
Things you or your spouse own, like bank accounts or real estate;
Money or property you, your spouse, or someone acting for you placed in a trust;
and
Any money or property which you and your spouse have a right to get but don't
get because of something:

*
*

You or your spouse did, or
Someone else did who was acting for you or at your request.

Medicaid may count some things as assets that we do not count for SSI.

WHAT HAPPENS WHEN YOU GIVE AWAY OR SELL AN ASSET
Medicaid may not pay for certain health care for you for a period of time if you,
your spouse. or someone else takes an asset of yours and gives it away or sells it for
less than what it is worth. Medicaid also may not pay for certain health care if your
assets are used to set up a trust that makes payments to someone else or cannot make
payments to you or for your benefit.
This rule usually applies to people in nursing homes and people in other places, such
as hospitals that give nursing services like those in nursing homes. This rule can also
apply to people who:
Get care at home or in their community under special programs called waivers. or
WiII soon need these services.
At times this rule also applies to people who are getting other kinds of services. such
as. home health care. help with activities of daily living. or other forms oflong-tenn
care.

Form SSA-J989-0CR-SI\1-F"ST-F"AC (7-2006)

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Important
Information
About Medicaid
(continued)

REPORTING TO YOUR STATE MEDICAID AGENCY
Your State Medicaid agency uses these rules about assets to decide if you can get
Medicaid. SSA will give your State Medicaid agency information SSA has about any
assets you may have given away. You also must tell your State Medicaid agency any
time you give away or sell an asset or set up a trust.

IF YOU HAVE OUESTIONS ABOUT MEDICAID
If you have any questions about Medicaid, including how your assets can affect
coverage, please contact the State or local welfare, public health, or social services
agency that handles Medicaid. They can answer your questions about how your assets
affect your Medicaid.

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 26 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING 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, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Privacy Act

The Social Security Administration is authorized to collect information on this
statement under 1611 (c) of the Social Security Act and regulation 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
the child continues 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 the child's continuing eligibility for benefits.
Although the information you furnish on this statement is almost never used for any
other purpose than stated in the forgoing, there is the possibility that information may
be disclosed to another person or agency as follows: I. 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 ofYeterans Affairs).

Form SSA-3989-0CR-SM-FST-FAC (7-2006)

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