Application for Supplemental Security Income Form
FORM APPROVED
SOCIAL SECURITY ADMINISTRATION □ TEL OMB NO. 0960-0444
Form SSA-8001-F5 (12-2002)
Page 1
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.
DEFFERRED
FS-SSA APP
ABAP
FS-REFERRED
FILING DATE
Month, Day, Year
Actual or Protective
TYPE OF CLAIM
INDIVIDUAL WITH
INELIGIBLE SPOUSE
COUPLE
INDIVIDUAL
CHILD
CHILD WITH PARENTS
PART I – BASIC ELIGIBILITY
1.
First Name, Middle Name, Last Name
2. Birth (month,
day, year)
3. Sex
Male
Female
4. Social Security Number
5.
Spouse (Parent(s)) Name(s)
6. Birth (month,
day, year)
7. Sex
Male
8. Social Security Number(s)
Female
9.
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
Security Numbers
c. Father’s Other Names
Father’s Other Social Security
Numbers
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 or your spouse (parents) are blind or disabled, note the date the impairment began and type of impairment.
Your Answer
Date Impairment began
Type of impairment
Spouse’s (Mother’s) Answer
Father’s Answer
NOTE: If you (and your spouse applying for benefits) were United States citizens at birth, go to question 14.
13.
a. Are you a naturalized United States citizen or lawfully
admitted for permanent residence in the United
States?
Your Answer
YES NO
Spouse’s Answer, if filing
YES NO
b. If you are lawfully admitted for permanent residence,
give the month / day / year of lawful admission.
DATE (month, day, year)
DATE (month, day, year)
NOTE: If the individual or spouse applying for benefits is not a citizen or lawfully admitted for permanent
residence, explain in “Remarks.”
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