Printing L:\SUESFO~1\S8001.FRP - Social Security

SOCIAL SECURITY ADMINISTRATIONAPPLICATION FOR SUPPLEMENTAL SECURITY INCOMETELForm ApprovedOMB No. 0960-0444Do Not Write in This SpaceI am/We are applying for Supplemental Security Incomeand any federally administered State supplementationunder Title XVI of the Social Security Act, for benefitsunder the other programs administered by the SocialSecurity Administration, and where applicable, formedical assistance under Title XIX of the SocialSecurity Act.DEFERRED ABAPFS-SSA/APP FS-REFERREDFiling Date(Month, Day, Year)ReceiptProtectivePreferred Language:TYPE OF CLAIMIndividualIndividual withIneligible SpouseCouple Child Child with ParentsPART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment ofthe filing date month.1. First Name, Middle Initial, Last Name 2. SexMaleFemale3. Birthdate(month, day, year)4. Social Security Number5.Spouse's/Parent(s) Name(s)6. SexMale7. Birthdate(month, day, year)8. Social Security Number(s)FemaleDate of Marriage: (month, day, year)9.Other Name(s) and Social Security Number(s) you, your spouse/parents used:(a) Your Other Name(s) (including Maiden Name)Your Other Social Security Number(s)(b) Spouse's/Mother's Other Name(s) (including Maiden Name)Spouse's/Mother's Other Social SecurityNumber(s)(c) Father's Other Name(s)Father's Other Social Security Number(s)FORM SSA-8001-BK (01/2008) Destroy Prior EditionsPage 1

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 are filing for yourself, go to (a); if you are filing for a child, go to (e).YouYour Spouse, if filing(a) Are you unable to work because of illnesses,injuries, or conditions? YESNO YES NOGo to (b) Go to #13 Go to (b) Go to #13(b) Enter the date you became unable to work(month, day, year) (month, day, year)(c) What are your illnesses, injuries or conditions?Go to (c)Go to (c)(Brief Description) (Brief Description)(d) If you were unable to work because of illnesses, YESProvide name(s) andinjuries, or conditions before age 22, do you have aSocial Securityparent who is age 62 or older, unable to work becauseNumber(s) in Remarks.of illnesses, injuries, or conditions or deceased?Go to #13(e) When did the child become disabled? (month, day, year)(f) What are the child's disabling illnesses, injuries or conditions?Go to (d)NOGo to #13Go to (d)Go to (f)(a) Are you a naturalized United States citizen?Go to (g)(g) Does the child have a parent or stepparent who is YESNO62 or older, unable to work because of illnesses,Provide name(s) and Go to #13injuries, or conditions, or deceased?Social SecurityNumber(s) in Remarks.Go to #1313.If you (and your spouse filing for benefits) were a United States citizen at birth, go to #17; otherwise go to (a).(b) Are you an American Indian born outside theUnited States?(c) Check the block that shows your American Indian status.YouYour Spouse, if filingYESNO YESNOGo to #17 Go to (b) Go to #17 Go to (b)YouYour Spouse, if filingYESNO YESNOGo to (c) Go to (d) Go to (c) Go to (d)YouAmerican Indian born in Canada Go to #17Your Spouse, if filingAmerican Indian born in Canada Go to #17Member of a Federally recognized Indian Tribe;Name of Tribe: Go to #17Member of a Federally recognized Indian Tribe;Name of Tribe: Go to #17Other American IndianExplain in Remarks, then Go to (d)FORM SSA-8001-BK (01/2008)Page 2Other American IndianExplain in Remarks, then Go to (d)

13.(d) Check the block below that shows your current immigration status.YouYour Spouse, if filingAmerasian Immigrant Go to #14 Amerasian Immigrant Go to #14Lawful Permanent Resident Go to #14Lawful Permanent Resident Go to #14RefugeeDate of entry (month, day, year):Go to #16RefugeeDate of entry (month, day, year):Go to #16AsyleeDate status granted (month, day, year):Go to #16AsyleeDate status granted (month, day, year):Go to #16Conditional EntrantDate status granted (month, day, year):Go to #16Conditional EntrantDate status granted (month, day, year):Go to #16Parolee for One Year Go to #16Parolee for One Year Go to #16Cuban/Haitian Entrant Go to #16 Cuban/Haitian Entrant Go to #16Deportation/Removal WithheldDate (month, day, year):Go to #16Deportation/Removal WithheldDate (month, day, year):Go to #16OtherExplain in Remarks, then Go to (e)OtherExplain in Remarks, then Go to (e)14.(e) If you have status, or have applied for status, as the spouse, child, or parent of a child of a United Statescitizen, or a lawfully admitted permanent resident, Go to #15; otherwise Go to #17.(a) Date of Admission:You(month, day, year)Your Spouse, if filing(month, day, year)(b) Was your entry into the United States sponsoredby any person or promoted by an institution or group?YESGo to (c)NOGo to (d)YESGo to (c)NOGo to (d)(c) Give the following information about the person, institution or group:Name Address Telephone Number( )(d) What was your immigration status, if any, beforeadjustment to lawful permanent resident?You(month, day, year)Your Spouse, if filing(month, day, year)From:From:To:To:(e) If filing as an adult, did your parents ever work inYESNOthe United States before you were 18?Go to (f) Go to #16(f) Name and Social Security Number of parent(s) who worked.NameSocial Security NumberYESNOGo to (f) Go to #16NameFORM SSA-8001-BK (01/2008)Page 3Social Security Number

15.17.(a) Have you, your child, or your parent, beensubjected to battery or extreme cruelty while in theUnited States?(b) Have you, your child, or your parent filed apetition with the Department of Homeland Securityfor a change in immigration status because of beingsubjected to battery or extreme cruelty?16. Are you, your spouse, or parent an active dutymember or a veteran of the armed forces of theUnited States?(a) When did you first make your home in the UnitedStates?(b) Have you lived outside of the United States sincethen?YouYESNOGo to (b) Go to #17YESNOGo to #16 Go to #17YES Explain inRemarks, thenGo to #17NO Go to #17(month, day, year)YESNOGo to (c) Go to #18Your Spouse, if filingYESNOGo to (b) Go to #17YESNOGo to #16 Go to #17YES Explain inRemarks, thenGo to #17NO Go to #17(month, day, year)YESNOGo to (c) Go to #18(c) Give the date(s) of residence outside the UnitedStates.DateLeft:DateReturned:(month, day, year)(month, day, year)DateLeft:DateReturned:(month, day, year)(month, day, year)18.19.(a) Have you been outside the United States (the 50States, District of Columbia and Northern MarianaIslands) 30 days prior to the filing date?(b) Give the date (month, day, year) you left theUnited States and the date you returned to the UnitedStates.(a) Do you have any unsatisfied felony warrants foryour arrest?(b) In which State or country was the warrantissued?YESNOGo to (b) Go to #19DateLeft:DateReturned:(month, day, year)(month, day, year)YouYESNOGo to (b) Go to #20Name of State/CountryGo to (c)(c) Was the warrant satisfied? YES NOGo to (d) Go to #20YESNOGo to (b) Go to #19DateLeft:DateReturned:(month, day, year)(month, day, year)Your Spouse, if filingYESNOGo to (b) Go to #20Name of State/CountryGo to (c)YESNOGo to (d) Go to #20(d) Date warrant satisfied:month, day, yearmonth, day, year20.(a) Do you have any unsatisfied Federal or Statewarrants for violating the conditions of probation orparole?(b) In which State or country was the warrantissued?YouYour Spouse, if filingYES NOYES NOGo to (b) Go to #21 Go to (b) Go to #21Name of State/Country Name of State/CountryGo to (c)Go to (c)(c) Was the warrant satisfied?(d) Date warrant satisfied:YES NOGo to (d) Go to #21month, day, yearYES NOGo to (d) Go to #21month, day, yearFORM SSA-8001-BK (01/2008)Page 4

PART II LIVING ARRANGEMENT (Use "Remarks" to explain any change between the firstmoment of the filing date month and today.)21. (a) Mark the box that describes where you live.House, Apartment, Mobile Home, Houseboat Noninstitution (rest home, retirement home orgroup home)Room in commercial establishmentInstitution (hospital, rehabilitation center, prison orschool)Room in private homeTransient(b) Date you began living there:(month, day, year)22. Mark the box that describes with whom you live. If you live in a foster home, group home, or an institution, orif you are a transient, do not answer but explain in remarks.Alone Spouse/Parents and/or Children Other PeoplePART III - RESOURCES (Show resources as of the first moment of the filing date month. Use"Remarks" to explain any changes.)23.If you own, or your name or your spouse's/parent's name(s) appear on any of the following items (either aloneor with other people's name(s)), enter the total cash value of item(s) on each line.a. Vehicles (cars, trucks,boats, motorcycles).YESNODescription of ItemsMarked YESCo-ownedWith OthersYes NoDollar ValueYou OwnDollar ValueSpouse orParents OwnHow many?b. Insurance policies$ $c. Cash at home, withyou, or anywhere elsed. Savings, checkingaccounts, stocks, bondse. Trust(s)$$$$$$$$f. Property other than thehome you live in$$g. Life estates orproperty you inherited$$h. Other items that canbe turned into cash$$FORM SSA-8001-BK (01/2008)Page 5

24. Are there any assets set aside to meet burial expensesfor you or your spouse/parent(s)? (If "Yes" describethe item in "Remarks".)25.(a) Have you or your spouse sold, transferred title,disposed of or given away, any money or otherproperty, including money or property in foreigncountries, since the first moment of the filing datemonth or within the 36 months prior to the filing datemonth?(b) If you co-owned any money or property withanother person(s), did you or any co-owner sell,transfer, or give away any co-owned money orproperty within the 36 months prior to the filing datemonth?Your Answer YES NOSpouse's Answer YES NOMother's Answer YES NOFather's Answer YES NOYouYour SpouseYES NO YES NOYouYour SpouseYES NO YES NOIF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH, GO TO #26.(c) OWNER'S/CO-OWNER'S NAME DESCRIPTION OF PROPERTY DATE OF DISPOSALItem#1Item #2Item #3Item #1Item #2Item #3Item #1Item #2Item #3NAME AND ADDRESS OFPURCHASER OR RECIPIENTSALE PRICE OR OTHERCONSIDERATIONRELATIONSHIP TO OWNERARE OTHER CONSIDERATIONS ORPROCEEDS EXPECTED? EXPLAIN$$$VALUE OF PROPERTY AND/ORAMOUNT OF CASH GIFTDO YOU STILL OWN PART OFTHE PROPERTY?YES NOYES NOYES NOSOLD ON OPEN MARKET? GIVEN AWAY? TRADED FORGOODS/SERVICES?Item #1Item #2YES NO YES NOYES NO YES NOYES NOYES NOItem #3YES NO YES NOFORM SSA-8001-BK (01/2008)Page 6YES NO

PART IV - INCOME (List all income received since the first moment of the filing date month orexpected in the next 3 months.)26. List cash, checks, and direct payment to bank accounts you (your spouse/parents) received or expect toreceive. Include income from wages, sick pay, self-employment, interest, social security, assistance based onneed, VA, gifts, pensions, and any other type of income. Give date last paid if income will stop in the next 3months. Also note here if anyone pays any bills for you directly or gives you money to pay them.Person ReceivingIncomeType of Income Amount FrequencyReceived$Date LastPaidSource ofIncome$$$27. (a) Does your spouse/parent pay court ordered childsupport?(b) Give the amount and frequency of payment:$PART V - FOOD STAMPSYESGo to (b)NOGo to #2828. (a) Are you currently receiving food stamps?(b) Have you received a recertification notice withinthe past 30 days?YouYESNOGo to (b) Go to (c)YESNOGo to (e) Go to #29Your Spouse, if filingYESNOGo to (b) Go to (c)YESNOGo to (e) Go to #29(c) Have you filed for food stamps in the last 60 days? YESNO YES NOGo to (d) Go to (e) Go to (d) Go to (e)(d) Have you received a favorable decision?YESGo to #29NOGo to (e)YESGo to #29NOGo to (e)(e) May I take your food stamp application today?YESGo to #29NOExplain in (f)YESGo to #29NOExplain in (f)(f) Explanation:PART VI- MISCELLANEOUSANSWER #29 ONLY IF YOU ARE REQUESTING BENEFITS ON BEHALF OF SOMEONE ELSE; OTHERWISEG0 T0 #30.29. Name of Person Requesting Benefits Relationship to Claimant Your Social Security NumberFORM SSA-8001-BK (01/2008)Page 7

PART VII - REMARKS - Use this space for any explanations.FORM SSA-8001-BK (01/2008)Page 8

PART VIII -- IMPORTANT INFORMATION -- PLEASE READ CAREFULLY30. The Social Security Administration will check your statements and compare its records with records fromother State and Federal agencies, including the Internal Revenue Service, to make sure you are paid the correctamount.PART IX - SIGNATURES31. I declare under penalty of perjury that I have examined all the information on this form, and on anyaccompanying statements or forms, and it is true and correct to the best of my knowledge. I understand thatanyone who knowingly gives false information, or causes someone else to do so, commits a crime and may besent to prison, or may face other penalties, or both.32.33.Your Signature (First name, middle initial, last name) (Write in ink.) Date (Month, day, year)SIGNHERETelephone Number(s) where we can contact youduring the day:( ) -Spouse's Signature (First name, middle initial, last name) (Write in ink.) (Sign only if applying for payments.)SIGNHERE34.Applicant's Mailing Address (Number & Street, Apt. No., P.O. Box or Rural Route)City and State ZIP Code Enter name of county (if any) in which youlive35.Claimant's Residence Address (If different from applicant's mailing address)City and State ZIP Code Enter name of county (if any) in which youlive36.If you are blind, check the type of mail you want to receive from us:Certified Regular Regular with a follow-up phone call37.WITNESSESYour application does not ordinarily have to be witnessed. If, however, you have signed by mark (X), twowitnesses to the signing, who know you, must sign below giving their full address.1. Signature of Witness 2. Signature of WitnessAddress (Number and Street, City, State, and ZIP Code)Address (Number and Street, City, State, and ZIP Code)FORM SSA-8001-BK (01/2008)Page 9

RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOMEName Social Security Number DateName Social Security Number DateIf you have a question or something to report call:Social Security Office you may visit or write to:( ) -Your application for Supplemental Security Income will be processed as quickly as possible. You should hear fromus within _____days. If you do not hear from us within that time, please get in touch with us in person, by mail, orcall us at the telephone number shown at the top of this page.We may need more information before we can decide whether or not you are eligible for SSI payments. If we needmore information, we will contact you. In the meantime, if you move or change your mailing address, you (orsomeone for you) should report the change to the office shown at the top of this page.You (or someone for you) must let us know if your immigration status changes.Also, you (or someone for you) must let us know if you are admitted to a hospital or other medical facility. Youcould lose some SSI payments if you do not let us know right away.Always give your Social Security Number when writing or telephoning about your claim. If you have any questionsabout your claim, we will be glad to help you.PRIVACY/PAPERWORK ACT NOTICESection 1631(e) of the Social Security Act authorizes the collection of information requested on this form. Theinformation you provide will be used to enable the Social Security Administration to determine if you are eligible forSupplemental Security Income payments. You do not have to give us the information requested. However, if youdo not provide the information, we will be unable to make an accurate and timely decision on your claim which mayresult in loss of some payments. We may provide information collected on this form to another Federal, State, orlocal government agency to assist us in determining your eligibility for SSI payments or if a Federal law requires therelease of information.We may also use the information you give us when we match records by computer. Matching programs compareour records with those of other Federal, State, or local government agencies and financial institutions. Manyagencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federalgovernment. The law allows us to do this even if you do not agree to it.Explanations about these and other reasons why information you provide us may be used or given out are availablein Social Security offices. If you want to learn more about this, contact any Social Security office.Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, asamended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questionsunless we display a valid Office of Management and Budget control number. We estimate that it will take about18-19 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORMTO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in yourtelephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our timeestimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to ourtime estimate to this address, not the completed form.FORM SSA-8001-BK (01/2008)Page 10