Form SSA-8000-BK Application for Supplemental Security Income (Revised)

o TEL

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No 0960-0229

Do Not Write In Thl. Space

APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)

DATE STAMP

Note: Social Security Administration staff or others who help people apply for
551 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.

Filing Date (month, day, year)

o

o

Receipt

Protective

o FS-SSA/APP I 0

FS-REFERRED

Preferred Language
Written:
Spoken:

TYPE OF CLAIM

O

Individual

0

0

Individual with
Ineligible Spouse

Couple

o

o

Child

Child with Parents

PART I--BASIC ELiGIBILlTY-- Answer the questions below beginning with the first moment of
the filing date month.
_
1. (a) First Name, Middle Initial. Last Name

Birthdate

Sex

o Male
o Female

Social Security Number

(month, day, year)

o

{b) Did you ever use any other names (including
maiden name) or any other Social Security Numbers?

0

{c) Other Name(s)

Other Social Security Number(s) used

YES

Go to {c)

NO

Go to (d)

(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:
Father's
Name:

Mother's
Maiden Name:

Go to #2'

~~, Applicant's Mailing Address (Number & Street. Apt. No. P.O. Box, Rural Route)
City and State

3~. Claimant's Residence Address

IZIP Code
(If different from applicant's mailing address)

City and State

t.t ".

IZIP Code

-I County

DIRECT Dt:POSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)
Routing Transit Number
Account Number
OEnroll in Direct Express
OChecking
OSavings

-.-

Icounty

_...

.

ODirect Deposit RefuSed.
. ..

5 ~.

(a) Are you married?
(b) Date of marriage:

DYES

o

Go to (b)

NO

Go to #~

(month, day, year)

Birthdate

(C) Spouse's Name (First, middle initial, last)

Social Security Number

(month, day, year)

o

(d) Did your spouse ever use any other names
(including maiden name) or Social Security Numbers?

DYES

(e) Other Name(s)

Other Social Security Number(s) Used

(f) Are you and your spouse living together?

0

(g) Date you began living apart:

(month, day, year)

Form SSA-8000-BK ter~ Ef (er~)
Destroy Prior Editions?
(~Ol J

aou

Page 1

YES

Go to (e)

Go to

#16

0

NO

Go to (f)

NO

Go to (9)

5 1J.

(h) Address of spouse or name of someone who knows where spouse is. (Complete only if spouse is age 65,
blind or disabled.)

You

(a) Have you had any other marriages?
If never married, check this box
D

DYES
Go to (b)

Your Spouse, if filing

D NO
Go to

#11

DYES
Go to (b)

D NO
Go to

#17

(b) Give the following information about your former spouse. If there was more than one former marriage,
show the remaining information in Remarks and go to #4.
YOU

YOUR SPOUSE

FORMER SPOUSE'S NAME
(including maiden name)
BIRTHDATE
(month, day, year)

SOCIAL SECURITY
NUMBER
DATE OF MARRIAGE
(month, day, year)
DATE MARRIAGE ENDED
(month, day, year)
HOW MARRIAGE ENDED

.7 I-

If you are filing for yourself, go to (a); if you are filing for a child, go to (e).
Your Spouse

You

(a) Are you unable to work because of illnesses,
injuries or conditions?

DYES
Go to (b)

DYES
D NO
Go to #rJ~ Go to (b)

(month, day, year)

D
NO
Go to #rp

J>

(month, day, year)

(b) Enter the date you became unable to work.
(c) What are your illnesses, injuries or conditions?
You

Your Spouse
Go to (d)

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?
DYES

Parent's Name:
Social Security Number:
Address:

DNO

Go to #5
(month, day, year)

(e) When did the child become disabled?
Go to (f)
(f) What are the child's disabling illnesses, injuries or conditions?

Go to (g)
Form SSA-8000-BK ~~) Ef ~-~)

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1. 01011

Page 2

7l

(g) Does the child have a parentIs) who is age 62 or older, unable to work because of illness, injuries, or
conditions, or deceased?
DYES

Parent's Name:
Social Security Number:
Address:

DNa

/J.

Go to #~

Birthplace

City

Country (if other than the U.S.)

State

You
Your Spouse,
if filing

9 1·
1-

9

Go to #~
You
Your Spouse, if filing
DYES
DNa
DYES
NO
Go to #r16 Go to #~/d Go to #vll/i Go to #~/()

0

Are you a United States citizen by birth?

.

Are you a naturalized United States citizen?

~. (a) Are you an American Indian born outside the
United States?

DYES
DNa
DYES
Go to #n.15 Go to #~II Goto#~~

0

DYES
Go to (b)

DNa
Go to (c)

DNa
Go to (c)

DYES
Go to (b)

NO

Goto#1/L

(b) Check the block that shows your American Indian status.
Your Spouse, if filing

You

o
o
o

15

American Indian born in Canada

Go to #11
Member of a Federally recognized Indian Tribe;

15

Go to #)1.

Name of Tribe
Other American Indian
Explain in Remarks, then Go to (c)

o
o
o

IS

American Indian born in Canada

Go to #Yl
Member of a Federally recognized Indian Tribe;
Name of Tribe

Go to

#t{

Go to

#t

Other American Indian
Explain in Remarks, then Go to (c)

(c) Check the block below that shows your current immigration status
Your Spouse, if filing

You

o
o
o
o
o
o
o
o
o

If

o
o
o

Go to #~

1'1

o Asylee
Date status granted:

Go to #11

Conditional Entrant
Date status granted:

I~

Amerasian Immigrant

Go to

Lawful Permanent Resident

Go to I)!

Refugee
Date of entry:

Go to

Asylee
Date status granted:
Conditional Entrant
Date status granted:
Parolee for One Year

Go to

Cuban/Haitian Entrant

Other
Explain in Remarks, then Go to (d)

Form SSA-8000-BK (~~ Ef (~J9+e)

JOIl

#Yt

o
1£ o
#)if
1'1 o
o
#fA
o

Go to #1r"f

Deportation/Removal Withheld
Date: .

?

#tJ
I~

.~ aOl I

Go to

Page 3

Amerasian Immigrant
Lawful Permanent Resident

IR
IJ

Go to #g
Refugee
Date of entry:

Parolee for One Year

Go to

#';AI

Go to

#MI

Go to #j{fflif
Go to #Yr IJj

Cuban/Haitian Entrant
Go to
Deportation/Removal Withheld
Date:
Other
Explain in Remarks, then Go to (d)

fll

#~

1'1

Go to #X

II ~.
/~ l

(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 #~; otherwise Go to

#11.15

If you are lawfully admitted for permanent

residence~'"
You

Your Spouse

(month, day, year'

(a) Date of Admission
(b) Was your entry into the United States sponsored
by any person or promoted by an institution or group?

DYES
Go to (c)

(month, day, year'

NO
D
Go to (d)

DYES
Go to (c)

D NO
Go to (d)

(c) Give the following information about the person, institution, or group, then Go to (d):
Name

Address

Telephone Number

(d) What was your immigration status, if any, before
adjustment to lawful permanent resident?

Your Spouse, if filing

You

Status:

Status:

(month, day, year'

(e) If filing as an adult, did your parents ever work in
the United States before you were age 18?

-

)

(

(month, day, year'

From:

From:

To:

To:

Go to (e)

D NO 1'1 DYES
Go to #y!' Go to (f)

DYES
Go to (f)

D NO
Go to #y(A

(f) Name and Social Security Number of parentIs) who worked.

}1.

Your Spouse, if filing
DYES
D NO

You

DYES

DNO

Go to (b)

Go to #'),4

/7

/~

14.

(b) Give the date (month, day, year) you left the
United States and the date you returned to the
United States.

Date Left:

Date Left:

Date Returned:

Date Returned:

IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #14/7
IF YOU ARE MARRIED AND YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY INCOME AND
YOUhlVED TOGETHER AT ANY TIME SINCE THE FIRST MOMENT OF THE FILING DATE MONTH, GO TO
#~~ OTHERWISE GO TO #~/P
(a) Is your spouse/parent the sponsor of an alien who
~
YES Go to (b)
No Go to #~
is eligible for supplemental security income?

o

(b) Eligible Alien's Name

o

Eligible Alien's Social Security Number

l-!5': (a) Do you have any unsatisfied felony warrants for

I~

You

your arrest?

(b) In which state or country was this warrant issued?

ONO

Go to (b)

Go to #¥6

Name of State/Country

o

(c) Was the warrant satisfied?

Go to (c)
YES

Go to (d)

19

ONO

Ip

Go to #~

o

(a) Do you have any unsatisfied Federal or State
warrants for violating the conditions of probation or
parole?

o

YES
Go to (b)

o

/.

Go to (b)

Go to #Kff
Name of State/Country

o

Go to (c)
YES

Go to (d)

(month, day, year)

(d) Date warrant satisfied

.11r.

/?

OYES

Go to #~
Your Spouse, if filing
YES
NO

o

NO

Goto#~

(month, day, year)

Your Spouse, if filing
You
r¥q
NO .yO
YES
ONO
Go to #J,II Go to (b)
Go to #1f"r

o

o

Name of State/Country

Name of State/Country
(b) In which state or country was the warrant issued?

o

(c) Was the warrant satisfied?

Go to (c)

Go to (c)
YES

OYES

ONO

ONO

c?o

a{J
Go to (d)

Go to #)1'/

(month, day, year)

(d) Date warrant satisfied

Go to (d)

Go to #:r-I

(month, day, year)

PART II - LIVING ARRANGEMENTS - The questions in this section refer to the signature date.
~

Check the block which best describes your present living situation:

0

Since (month, day, year)
Household
Go to /Iff

0
0
0

Since (month, day, year)

Non-Institutional Care

Go to #~
Since (month, day, year)

Institution

Go to #+STransient

Form SSA-8000-BK

or ftJrne/ms

(~~

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(~ ~, 8)

?. caOh

Since (month, day, year)
Goto~

Page 5

INSTITUTION
~

~/

.w.

t9J

Check the block that identifies the type of institution where you currently reside. then Go to
D

School

D

Rehabilitation Center

D

Hospital

D

Jail

D

Rest or Retirement Home

D

Other (Specify)

D

Nursing Home

#Y!f'¥:(

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:

Goto#~
NON-INSTITUTIONAL CARE

'3

Check the block that best describes your current residence. then Go to #~:Ji.J
D

Foster Home

D

o

Group Home

Other (Specify)

.21': Give the following information about your Noninstitutional Care:

'I

(a) Name of facility where you live:
(b) Name of placing agency

Telephone Number

Address

(

-

)

(c) Does this agency pay for your room and board?
DYES

Go to #8'5"~ D

NO If NO. who pays?

Go to #~Lm
-0-

HOUSEHOLD ARRANGEMENTS

zr.

'5

2'$,

Check the block that describes your current residence. then Go to

#2'3:J b

D

House

0

Mobile Home

D

Apartment

D

Houseboat

0

Room (private home)

0

Other (Specify)

0

Room (commercial establishment)

Do you live alone or only with your spouse?

Form SSA-8000-BK

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d.OlJ

DYES
Page 6

Go to

#;l!JJ)

0

NO

Go to If.2t(,

~ \(a)

Give the following information about everyone who lives with you:
Public
Assistance
Name

Relationship

YES

NO

Sex
M F

Blind or
Disabled

If Under 22

Birthdate
Student
Married
mm/dd/yy YES NO YES NO YES NO

If anyone listed is under age 22 and not married, Go to (b); otherwise, Go to

~7a)

(b) Does anyone listed in
who is under age 18, OR
between ages 18-22 and a student, receive income?

DYES

#1I!f.,;J)

Go to (c)

D

NO
Go to
Monthly Amount

Source and Type

(c) Child Receiving Income

Social Security
Number

$
$
$
$
$
$
~. (a) Do you (or does anyone who lives with you) own

DYES

or rent the place where you live?
Form SSA-8000-BK

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(~~)

7.

aOI,

Page 7

Go to #~9

D

No

Go to (b)

~

(b) Name of person who owns or
rents the place where you live

Telephone Number

Address

(

(c) If you live alone or only with your spouse, and do not own or rent, Go to

2:6.

9

(a) Are you (or your living with spouse) buying or do
you own the place where you live?

D

(b) Are your parentIs) buying or do they own the place
where you live?

D

#~.;:e'otherwise,

YES
Go to (c)

YES

-

)

D

Go to (c)

Go to

#~.,j,;;

No
If you are a child living
with your parentIs) Go
to (~ otherwise Go to
#-;1. (1
NO

D

Go to #~30

(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 #~ otherwise Go to #~3.(
-0

)!f". (a) Do you (or your living with spouse) have rental

0

D

YES

Go to (d)

D

NO
If you are a child living
with your parentIs) Go to
(b); otherwise Go to (c)

YES

Go to (d)

D

NO

liability for the place where you live?

(b) Does your parentIs) have rental liability?

D

Go to (c)

(c) Does anyone who lives with you have rental liability for the place where you live?
D

YES Give name of person with rental liability:

Go to #?£.3.

DNO Give name of person with home ownership:
I

Got 0

#,,2'r!S,.

(d) What is the amount and frequency of the rent payment?
Amount:

$

Frequency of Payment:
Go to #}It{..

~

/

(a) Are you (or anyone who lives with you) the parent
or child of the landlord or the landlord's spouse?
(b) Name of person related to landlord
or landlord's spouse

Relationship

DYES

Go to (b)

D

NO

Go to (c)

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 #~.3"8
~

:;)

(a) Does anyone living with you contribute to the
household expenses? (NOTE: See list of household
expenses in

DYES

#2J4137

(b) Amount ot'h;;s contribute:

aou

D

NO
Goto

#~

$

Form SSA -8000-BK (.e%-~ Ef ~-z.e+et

?.

Go to (b)

?.

at)I I

Go to #$'0
Page 8

.Je': (a) Do you eat all your meals out?
(b) Do you buy all your food separately from other
household members:

D

YES

Go to

#~3'1

D

NO

Go to (b)

D

YES

Go to

#~3
DATE OF DISPOSAL

ITEM #1
ITEM #2
ITEM #3
NAME AND ADDRESS OR
PURCHASER OR RECIPIENT

VALUE OF PROPERTY AND/OR
AMOUNT OF CASH GIFT

RELATIONSHIP TO OWNER

ITEM #1

$

ITEM #2

$

ITEM #3

$
SALES PRICE OR OTHER
CONSIDERATION

ARE OTHER CONSIDERATION OR
PROCEEDS EXPECTED? EXPLAIN.

DO YOU STILL OWN PART OF THE
PROPERTY?

ITEM #1
ITEM #2
ITEM #3
SOLD ON OPEN MARKET?

ITEM #1
ITEM #2

0
0
0

YES
YES

o
o

NO
NO

YES
ITEM #3
ONO
Form SSA-8000-BK 102=201 OJ Ef (er-~

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GIVEN AWAY?

0
0
0

YES

o

YES

ONO

YES

NO

ONO

Page 14

TRADED FOR GOODS/SERVICES?

0
0
0

YES
YES
YES

o
o
o

NO
NO
NO

~. (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 #~ and #i8~7

(b) DESCRIPTION (Where appropriate, give
name & address of organization and account/
policy number.)

You
DYES
Go to (b)

Your Spouse

D

NO

Goto~

WHEN SET
ASIDE

VALUE

DYES

D

Go to (b)

NO

Go to

#~'1

OWNER'S NAME

(month, day, year)

Item 1

$
Item 2

$
FOR WHOSE BURIAL

IS ITEM IRREVOCABLE?

Item 1

D

YES

D

NO

WILL INTEREST EARNED OR APPRECIATION
IN VALUE REMAIN IN THE BURIAL FUND?
DYES Go to #ft6

D

NO

Jf9
Explain in (c)

Item 1

D

YES

D

NO

DYES
Goto

D

#~rj

NO

Explain in (c)

(c) EXPLANATION

;t6.

9

(a) Do you own any cemetery lots, crypts, caskets,
vaults, urns, mausoleums, or other repositories for
burial or any headstones or markers?
(b) Owner's Name

Description

You
DYES

D

Go to (b)

Go to

For Whose Burial

NO 50

#yJ

Your Spouse
DYES
D NO
Go to (b)

Relationship to You
or Your Spouse

~

Go to #M'

Current Market Value

$
$

$
Go to #k7"
Form SSA-8000-BK

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Page 15

PART IV -- INCOME
~

()

(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?
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 ~~~J~~tate, Local. Private, Union, Retirement or Disability)
Military Special Payor 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 (6'2*z010:) Ef

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Pa ge 16

Your Spouse

You
YES

NO

YES

NO

.(,
M. (b) Give the following information for any block checked YES in

()
Person
Receiving
Income

Type of Income

Amount
Received

I

#4I1(a); otherwise, Go to #~I

Source (Name,
Frequency of Date Expected Address of Person,
Payment
or Received Bank, Organization,
or Company)

Identifying
Number

$
$
$

1\/

IF YOU EVER RECEIVED SSI BEFORE, GO TO #~; OTHERWISE GO TO

~

5~

:?3

Your Spouse

You

..iIo6: Are any overpayments being collected from benefits

I

#)16.50/

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?
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?
(a) Have you (or your spouse) received wages or sick
pay since the first moment of the filing date month
through the current month?

o

DYES
Explain in
Remarks,
then Go to

NO

Go to

o

DYES

#~

SlY

NO

Goto~

Explain in
Remarks,
then Go to

#~S¥

#4JKS~

o

DYES
NO
Explain in
Goto~
Remarks,
then Go to #~
DYES

o

Go to (b)

Go to (e)

NO

DYES
Explain in
Remarks,
then Go to

o

NO
Go to #~

#5t)S~

DYES

o

Go to (b)

Go to (e)

NO

(b) Name and Address of Employer (include telephone number and area code, if known)
Your Spouse

You

Go to (c)

Go to (c)
(c)

Date last worked
(month, day, year)

Date next paid
(month, day, year)

Date last paid
(month, day, year)

You
Your
Spouse
(d) Total monthly wages received (before any
deductions)

(e) Do you (or your spouse) expect to receive any
wages in the next 14 months?

Your Amount

Your Spouse's Amount

$

$
You

DYES
Go to (f)

(f) Name and address of employer if different from
You

~(b)

?. dOli

~2e"t9l

'/. dOl (

NO

5'1

Go to *&f

Your Spouse
DYES
DNO
Go to (f)

(include telephone number, if known)

Your Spouse

Form SSA-8000-BK I'M--2e4-Ot-Ef

o

Page 17

Sf

Goto~

'!to': (g) Give the following information:

5.l3

RATE OF PAY

You

$

Your
Spouse

$

HOW OFTEN.
PAID

AMOUNT WORKED
PER PAY PERIOD

(h) Do you expect any change in wage information
provided in ~g)

DYES
Go to (i)

PAY DAY OR
DATE PAID

You
D NOSr
Go to #hf

DATE LAST PAID
(month, day, year)

Your Spouse
DYES
D NO
Go to (i)
Go to It81

S'y

(i) Explain Change:

You

'I

Your Spouse

(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?
(b) Give the following information; then Go to If'!!J'Z
Date(s) Self-Employed

Date(s) Self-Employed

You

DYES
Go to (b)

D

Goto~

"S

Type of Business

Last Year's:
Gross Income

Type of Business

have any special expenses that you paid which are
necessary for you to work?

~

D NO
Go to IIIiJIr

Ss

Last Year's:
Net Profit

Last Year's:
Net Loss

$

$

$

This Year's:
Gross Income

This Year's:
Net Profit

This Year's:
Net Loss

"t12'. If you or your spouse are blind or disabled. do you

,

DYES
Go to (b)

5.5

$

5

Your Spouse

NO

DYES
Explain in
Remarks;
then Go to

You
Your Spouse
D NO
DYES
D NO
Goto~
Go to #~ Explain in
Remarks;
Si
then Go to

trtJ3S(;
(a) Does your spouse/parent who lives with you have
to pay court-ordered support?

DYES Go to (b)
Amount:

(b) Give amount and frequency of court-ordered
support payment.

$

$

#~

D

NO Go to NOTE

Frequency:

$
Go to (c)
Name:

Address:

(c) Give the following information about the person
who receives these payments:

NOTE: IF YOU ARE FILING AS A CHILD AND YOU ARE EMPLOYED OR AGE 18 - 22 (WHETHER EMPLOYED
OR NOT). GO TO ~ OTHERWISE, GO TO I,f~}

57

Form SSA-8000-BK

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Page 18

D

YES Go to (d)

D

NO Go to (b)

(b) Have you been out of school for more than 4
calendar months?

D

YES Go to (c)

D

NO Go to (c)

(c) Do you plan to attend school regularly during the
next 4 months?

D YES Explain absence
in Remarks and Go to (d)

D

NO Go to

"5ot: (a) Have you attended school regularly since the filing

7

Cd;

date month?

Name of School

Dates of Attendance
From
To

Name of School Contact

#S5'5J>

Course of Study

Hours Attending or
Planning to Attend

Phone Number

PART V - POTENTIAL ELIGIBILITY FOR FOOD STAMPS/MEDICAL ASSISTANCE/OTHER
BENEFITS - If a California resident, Skip to 1I'f1ft59
"5ti. (a) Are you currently receiving food stamps?

DYES
Go to (b)

(b) Have you received a recertification notice within the DYES
Go to (e)
past 30 days?

You
D

NO
Go to (c)

N~;l

Your Spouse, if filing
DYES
D NO
Go to (b)
Go to (c)

D
Go to

DYES
Go to (e)

D NO
Go to #fJO..

DYES
Go to (d)

D NO
Go to (e)

(c) Have you filed for food stamps in the last 60 days?

DYES
Go to (d)

D NO
Go to (e)

(d) Have you received an unfavorable decision?

DYES
Go to (e)

D NOS? DYES
Go to (e)
Go to #fr6"

oGoNOto #f!f5

(e) If everyone in the household receives or is applying for SSI. Go to (f); otherwise Go to #&fr.Sf}

o

D YES~9
NO
YES~ D NO
Explain in (g)
Go to #
Explain in (g) Go to #

0

(f) May I take your food stamp application topay?
(g) Explanation:

"5'6'. 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 father 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.

-59

IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to (b).
You

Your Spouse, if filing

(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?

DYES
Go to (b)

(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.)

DYES
Go to (c)

D NO
Go to (c)

DYES
Go to (c)

D NO
Go to (c)

(c) Do you have any unpaid medical expenses for the
3 months prior to the filing date month?

DYES
Go to #fj!

D NO
Go to #~

DYES

D NO
Go to #6J::

Form SSA-8000-BK

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D NO
Go to Itffr

'0

'V

DYES
Go to (b)

D NO
Go to IIfn-

('6

Goto~

.....,

"(.I

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0

(a) Have you ever worked under the U.S. Social
Security System?
(b) Have you, your spouse, or a former spouse (or
parent if you are filing as a child) ever:

D

YES Go to (b)

NO Go to (b)

Your
Spouse/Parent

You
Yes

D

No

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?
l

y

~Q.

You must tell Social Security

every time there IS a change-while we process your application AND if you start receiving SSI.

y 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 (er-~ Ef ~~
Page 22

•

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.

~ 0011

CHANGES TO REPORT

o

o

WHERE YOU LIVE --You must report to Social Security if:
• You move.
• You leave the United States for 30 consecutive days.
• You (or your spouse) leave your household for a
calendar month or longer. (For example, you enter a • You are no longer a legal resident of the United
hospital or visit a relative.)
States
• 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.

o

HOW YOU LIVE -You must report to Social Security:
• If anyone moves into or out of your household.
• Your marital status changes:
• If th~ amount of money you pay toward household
--You get married, separated, divorced, or your
expenses changes.
marriage is annulled.
• Births and deaths of any people with whom you live.
--You begin living with someone as husband and
• Your spouse or former spouse dies.
wife.

o

IINCOME-You must report to Social Security if you, your spouse/your parent(s)/other children living in your household:
• 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.

o
o

• 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 SS!.

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.

o
o

o

• You go to work.

YOU ARE UNMARRIED AND UNDER AGE 22 - A report to Socia
• You start or stop school

• You get married or divorced

:siHlYHrv

• You start or stop working

YOUR IMMIGRATION STATUS CHANGES• Xou 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
• You will no longer be able or no longer wish to act as
any changes listed above. (You may be held liable
that person's representative payee.
if you do not report changes that could affect the
SSI recipient's payment amount, and he/she is
overpaid.)
IF A WARRANT HAS BEEN ISSUED FOR YOUR ARREST -You must report to Social Security if:
• Your warrant is for a crime or an attempted crime
• Your warrant is for a violation of probation
that is a felony (or, in jurisdictions that do not define
or parole under Federal or State law.
crimes as felonies, a crime that is punishable by death
or imprisonment for a term exceeding 1 year); or

o

Form SSA-8000-BK ~~ Ef i&Z~

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Page 23

IF YOU ARE THE PARENT, STEP PARENT, OR REPRESENTATIVE PAYEE FOR A
CHILD UNDER AGE 18-A report to Social Security must be made if:
•
•
•

There is a change in any income the child, his or her parent(s), step parent, or brother(s)
or sister(s) receive.
There is a change in his or her parents' or step parent's marriage, a change in the value of
anything they own, or a change in their residence.
There is a change in the student status of the child's brother(s) or sister(s).