Sample SSI Change of Address Form
FS-SSA/A PP
FS-REF ERRED
Fil i n g Date
Month, Day, Year
Actual
or
Prot ective
Social Security Number
TEL
SOCIAL SECURITY ADMINISTRATION
Do n ot w r i te i n th i s s p ace
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Note: Social Security Administration staff or others who help people apply for
SSI will fill out this form for you.
Individual with
Coup le Individual
Child
TYPE OF CLAIM
Child w ith Parent(s)
Ineligible Spouse
PART I–B A SIC ELIGIBIL ITY–
The questions
in this section pertain to the period beginning with the first
moment of the filin g date month through the date this applic ation is signed
un l es s a q u es ti o n s p eci fi es a d i ff erent t im e peri o d.
Birth
(month, day
year)
1.
First Name, Middle Initial, Last Name
Sex
Social Security Number
Male
Did you ever use any other names
(including maiden name)
or other Social Security numbers?
YES
Go to (c)
NO
Go to #2
Other Names and Social Security Numbers Used
2.
Are you married?
YES
Go to (b)
NO
Go to #4
Spouse's Name
(First, middle initial, last)
Birth
(month, day, year)
Did your spouse ever use any other names (including
maiden name)
or other Social Security Numbers?
YES
Go to (d)
NO
Go to (e)
Other Names
(including maiden name)
and Social Security Numbers Used by Spouse
Are you and your spouse living together?
NO
Go to (f)
Address of spouse or name and address of someone who knows where the spouse is.
Date you began
living apart
3. (a) Is your spouse the sponsor of an alien for supplemental
YES
Go to (b)
NO
Go to #4
security income?
Alien's Social Security Number
(b) Alien's Name
FORM
SSA-8000-B K (5-90)
Destroy Prior Editions
Page 1
Form Approved
OMB No 0960-0229
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 medi cal assistance under
t it l e XIX of th e So c i al Secu r i ty Act .
Female
IF YOUR SPOUSE IS NOT FIL ING FOR SUPPLEMENTAL SECURITY INCOME A ND YOU SEPARATED
SINCE THE FIRST MOMENT OF THE FIL ING DATE MONTH GO TO #3. IF YOUR SPOUSE IS FILING
FOR SUPPLEMENTAL SECURITY INCOME, GO TO #4.
(g)
If your spouse
is not filing go to #3;
otherwise go to #4.
YES
/
/
/
/
(b)
(c)
(a)
(a)
(b)
(c)
(d)
/
/
(e)
(f)
Page 1/15
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Sample SSI Change of Address Form PDF
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