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Application For Supplemental Security Income

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Application For Supplemental Security Income
Application For Supplemental Security Income
FS-SSA/APP
FS-REFERRED
Filing Date
Month, Day, Year
Actual
or
Protective
Social Security Number
TEL
SOCIAL SECURITY ADMINISTRATION
Do not write in this space
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
Couple Individual
Child
TYPE OF CLAIM
Child with Parent(s)
PART I–BASIC ELIGIBILITY–
The questions
in this section pertain to the period beginning with the first
moment of the filing date month through the date this application is signed
unless a question specifies a different time period.
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-BK (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 medical assistance under
title XIX of the Social Security Act.
Female
IF YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY INCOME AND YOU SEPARATED
SINCE THE FIRST MOMENT OF THE FILING 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)
Application For Supplemental Security Income
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