Supplemental Security Income Application Sample
Form SSA-8000-BK (01-2012)
Destroy Prior Editions
SOCIAL SECURITY ADMINISTRATION
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Form Approved
OMB No. 0960-0229
Page 1
TEL
Note: Social Security Administration staff or others who help people apply for
SSI 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.
Do Not Write in This Space
DATE STAMP
Filing Date (month, day, year)
Receipt Protective
FS-SSA/APP
FS-REFERRED
Preferred Language
Written: Spoken:
TYPE OF CLAIM
Individual
Individual with
Ineligible Spouse
Couple
Child Child with Parents
PART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment of
the filing date month.
1.
(a) First Name, Middle Initial, Last Name Sex
Male
Female
Birthdate
(month, day, year)
Social Security Number
(b) Did you ever use any other names (including maiden
name) or any other Social Security Numbers?
YES Go to (c) NO Go to (d)
(c) Other Name(s) Other Social Security Number(s) used
(d) If you are also filing for Social Security Benefits, go to #2; otherwise complete the following:
Mother's
Maiden Name:
Father's
Name:
Go to #2
2.
Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)
City and State
ZIP Code County
3.
Claimant's Residence Address (If different from applicant's mailing address)
City and State ZIP Code County
4.
DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION)
Routing Transit Number Account Number
Checking
Savings
Enroll in Direct Express
Direct Deposit Refused
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