SOCIAL SECURITY ADMINISTRATION □ TEL OMB NO. 0960-0444
Form SSA-8001-F5 (12-2002)
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME
Do not write in this space.
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.
PART I – BASIC ELIGIBILITY
First Name, Middle Name, Last Name
2. Birth (month,
4. Social Security Number
Spouse (Parent(s)) Name(s)
6. Birth (month,
8. Social Security Number(s)
Other Names and Social Security Numbers you, your spouse (parents) used.
a. Your Other Names (including Maiden Name)
Your Other Social Security Numbers
b. Spouse’s (Mother’s) Other Names (including Maiden Name)
Spouse’s (Mother’s) Other Social
Father’s Other Social Security
Your Place of Birth (City and State or Foreign Country)
11. Spouse’s Place of Birth (City and State or Foreign Country)
If you or your spouse (parents) are blind or disabled, note the date the impairment began and type of impairment.
Spouse’s (Mother’s) Answer
NOTE: If you (and your spouse applying for benefits) were United States citizens at birth, go to question 14.
a. Are you a naturalized United States citizen or lawfully
admitted for permanent residence in the United
Spouse’s Answer, if filing
b. If you are lawfully admitted for permanent residence,
give the month / day / year of lawful admission.
NOTE: If the individual or spouse applying for benefits is not a citizen or lawfully admitted for permanent
residence, explain in “Remarks.”