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

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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 <strong>Social</strong> <strong>Security</strong> 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
Page 1 and 2: SOCIAL SECURITY ADMINISTRATIONAPPLI
Page 3 and 4: 13.(d) Check the block below that s
Page 5 and 6: PART II LIVING ARRANGEMENT (Use "Re
Page 7: PART IV - INCOME (List all income r

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