Fillable Printable Sample SSI Change of Address Form
Fillable Printable Sample SSI Change of Address Form
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)
(a) Are you lawfully admitted for permanent residence in the
United States?
Give the month, day, and year of lawful admission for
permanent residence. If date is within 3 years of the filing
date, go to (c); otherwise go to #11.
DATE DATE
(c)
You
Your
Spouse
(b)
GIVE THE FOLLOWING
INFORMATION:
DATE IMPAIRMENT
BEGAN
NATURE OF THE IMPAIRMENT
You
Your Spouse
Have you been outside the United States (the 50 states,
District of Columbia and Northern Mariana Islands) 30
days prior to the filing date?
Go to #8
(e) GO TO #11
You
4.
YES
YES NO
NO
Have you been married before?
Go to (b) Go to (b)
Go to #5
Go to #5
Give the following information about your former spouse. If there was more than one former marriage, show the
remaining information in Remarks and go to #5.
FORMER SPOUSE'S NAME
(including maiden name)
SOCIAL SECURITY NUMBER
(if none or unknown, so indicate)
5.
You
Your Spo use
(a) Are you blind or disabled?
Go to (b)
Go to #6
Go to #6
6.
In what city and State or foreign country were your born?
7.
Are you a United States citizen by birth?
You
Your Spou s e, if fi li n g
8.
Are you a naturalized United States citizen?
9.
(d) Give the following information about the person, institution, or group:
Name
Address
Telephone No.
(Include Area Code)
( __ __ __ ) -
10.
(a)
DATE
(month, day, year)
DATE
(month, day, year)
(b)
11.
DATE
(month, day, year)
DATE
(month, day, year)
When did you first make your home in the United
States?
Have you lived outside the United States since then?
FROM:
FROM:
(c)
Give dates of residence outside the United States.
(Month,
TO:
TO:
day, year)
12.
(a)
Date Left
Date Left
Date Returned
Date Returned
(b)
Give the date
(Month, day, year)
you left the United States
and the date you returned to the United States.
Page 2
FORM
SSA-8000-BK (5-90)
DATE OF
MARRIAGE
DATE MAR-
RIAGE ENDED
HOW MARRIAGE
ENDED
Your Spou s e, if fi li n g
Go to (b)
YES
YES NO
NO
Go to #11
Go to #8 Go to #11
YES
YES NO
NO
Go to #11
Go to #9
Go to #9
Go to #11
YES
YES NO
NO
Go to (b)
Go to #10
Go to #10
Go to (b)
YES
YES NO
NO
Go to (d)
Go to #11
Go to #11
Go to (d)
YES
YES NO
NO
You
Your Spou s e, if fi li n g
Go to (b)
Go to #11
Go to #11
Go to (b)
YES
YES NO
NO
Go to (c)
Go to #12
Go to #12
Go to (c)
YES
YES NO
NO
Go to (b)
Go to #13
Go to #13
Go to (b)
YES
YES NO
NO
(b)
(a)
Was your entry into the United States sponsored by any
person or promoted by an institution or group?
Is
the Immigration
and Naturalization Service
(
INS
)
aware
of
your presence in the United States?
Through what date will INS allow you to
remain
in the United
States? (If indefinitely, so indicate)
(a)
(b)
(b)
(a) Are you (or your living with spouse) buying or do you own the
place where you live?
YES
Go to (c)
(b) Are your parent(s) buying or do they own the place where
you live?
YES
Go to (c)
NO
Go to #18
If you are a child living
with parent(s) go to (b);
otherwise go to # 18.
NO
(d)
CHILD RECEIVING INCOME
SOURCE & TYPE
MONTHLY AMOUNT
$
$
$
PART II–LIVING ARRANGEMENTS–Th e q u es t i o n s i n t h i s s ec t i o n pert ai n t o th e s i g n at u r e dat e.
13.
Check the applicable block to show where you liv
e now:
INSTITUTIONS
House
Transient
School
Rehabilitation Center
Other (Specify)
Hospital
Jail
Apartment
Rest or Retirement Home
Other (Specify)
Mobile Home
Nursing Home
Foster Home
IF YOU A RE LIVING IN A FOSTER HOME, AN INSTITUTION, OR ARE A TRANSIENT, EXPLA IN IN
REMARKS AND GO TO #21.
14.
Do you liv
e alone or with your spouse only?
YES
Go to #16
NO
Go to #15
15.
(a) Give the following information about everyone who lives with you (or with you and your spouse):
SEX
IF UNDER AGE 22
NAME
M F
MARRIED
STUDENT
16.
(a) Do you (or does anyone who lives with you) own or rent the
YES
Go to #17
NO
Go to (b)
place where you live?
(b) Name and address of person who owns or rents the place where you live:
Telephone number, if known
(Include Area Code)
(c) GO TO #20
17.
Amount
Frequency of Payment
(c) What is the amount and frequency of the mortgage pay-
ment?
(d) GO TO #20
FORM
SSA-8000-B K (5-90)
Page 3
Room
(commercial
est ablishment)
Room
(private home)
RELATIONSHIP TO
YOU OR SPOUSE
DATE OF BIRTH
(Month, day, year)
BLIND OR
DISABLED
YES NO YES NO YES NO
$
(
— — —
)
(b) Do all the persons listed in 15(a) receive assistance or
income based on need?
YES
Go to (c)
NO
Go to (c)
(c) Does anyone listed in 15(a) who is not married and under
age 18 OR between ages 18-21, not married, and a student
receive income?
YES
Go to (d)
NO
Go to #16
Has the information given in items #13 through #20 been the
same since the first moment of the filing date month?
NO
YES
Explain in Remarks
and go to (b).
Go to (b)
Do you expect this information to change?
(b)
Explain in
Remarks and
go to #22.
YES
NO
Go to #22
$
$
$ $
$ $
Do you (or your living with spouse) have rental liability for
the place where you live?
(a)
NO
YES
Go to (d)
Do your parent(s) have rental liability?
(b)
NO
Go to (c)
YES
Go to (d)
Does anyone who lives with you hav
e rental liability for the
place where you live?
(c)
YES
NO
18.
Frequency of payment
What is the amount and frequency of the rent
payment?
Amount
$
19.
Are you (or anyone who lives with you) the parent or child of
NO
Go to #20
YES
Go to (b)
the landlord or the landlord's spouse?
Name and address of landlord (include telephone number
and area code, if known):
Relationship
Name of person related to landlord
or landlord's spouse:
20.
YES
Go to (b)
NO
Go to (c)
(b)
ITEM
CONTRIBUTOR'S NAME AND ADDRESS (TELEPHONE NUMBER
AND AREA CODE IF KNOWN)
MONTHLY
AMOUNT
MONTHS
RECEIVED
$
$
$
$
GO TO (d ) IF YOU (OR YOUR LIVING WITH SPOUSE) OWN OR RENT AND L IVE WITH OTHERS (OTHER THAN
SPOUSE ONLY) BUT YOU DO NOT LIVE IN A PUBLIC ASSISTANCE HOUSEHOLD; OTHERWISE, GO TO #21.
Does anyone living with you give you (or your living with
spouse) money for or help pay for all or part of your food,
rent or home mortgage payments, property insurance
required by the mortgage holder, real property taxes,
heating fuel, gas, electricity, garbage removal, water, or
sewer bills?
YES
NO
21.
PA RT III—RESOURCES—
Your Spo us e
YOU
22.
Do you own or does your name appear on the title of any
vehicles; e.g., cars, trucks, boats, motorc ycles, etc.?
YES
YES
NO
Go to (b)
Go to #23
Go to (b)
Go to #23
(b)
EQUIPPED FOR
HANDI CAPPED?
CURRENT
DESCRI PTION
AMOUNT
OWNER'S NAME
USED FOR
MARKET
(YEAR MAKE& MODEL)
OW ED
VALUE
NO
YES
FORM
SSA-8000-BK (5-90)
Page 4
If you are a child living
with parent(s) go to (b);
otherwise go to (c).
Give name of
person with rental
liability in Remarks
and go to #19.
Give name of person
with home ownership
in Remarks and go to
#20
Does anyone who does NOT live with you provide your
household with all or part of the food and shelter (including
payment of the bills for food, rent, or home mortgage pay-
ments, property insurance required by the mortgage holder,
real property taxes, heating fuel, gas, electricity, garbage
removal, water, or sewerage) or give the household money
for these items?
(a)
(b)
(c)
(d)
(a)
Go to #21 Go to #21
Th e q uest io ns i n th i s s ect i on p er t ai n t o t h e fi r st m om ent o f th e f il i ng
date mo n t h.
(a)
NO
(d)
(a)
Life estates or ownership interest in an unprobated estate?
Household or personal Items worth more than $500 each?
OWNER'S NA ME
NAME OF ITEM
VALUE
AMOUNT OWED
ON ITEM
WHERE APPROPRIATE, GIVE NAME AND AD-
DRESS OF BA NK OR OTHER ORGANIZATION
$
$
$
23.
Do you own or are you buying any life insurance
policies?
(b) Give the following Information on each policy:
OWNER'S NAME
NAME OF INSURED
NAME AND ADDRESS OF INSURANCE COMPANY
Policy (#1)
Policy (#2)
Policy (#3)
POLICY NUMBER
FACE VALUE
CASH SURRENDER
VALUE
DATE
PURCHASED
Policy (#1)
$ $
Policy (#2)
$ $
Policy (#3)
$ $
LOANS AGAINST
YES
NO
$
$
$
You
You r Spo u s e
24.
Do you (either alone or jointly with any other person) own any:
YES
NO
YES
NO
(b) Give the following Information for any "Yes'' answer in 24(a); otherwise go to #25
You
You r Spo u s e
25.
Do you own or does your name appear (either alone or with
any other person's name) on any of the following items?
YES
NO
YES
NO
Cash at home, with you, or anywhere else
Checking Accounts
Savings Accounts
Credit Union Accounts
Christmas Club Accounts
Certificates of Deposit
Notes
Stocks or Mutual Funds
Bonds
Other items that can be turned Into cash
(b) Give the following information for any "Yes'' answer in 25(a), otherwise go to #26
OWNER'S NAME
NAME OF ITEM
VALUE
NAME AND ADDRESS OF BANK OR
OTHER ORGANIZATION APPROPRIATE
IDENTIFYING
NUMBER
$
$
$
$
Page 5
FORM
SSA-8000-BK (5-90)
You r Spo u s e
You
YES
YES
NO
Go to (b)
Go to #24
Go to (b)
Go to #24
NO
(a)
(a)
$
(a)
You r Spo u s e
Yo u
Do you have any land, houses, buildings, real property, prop-
erty in foreign countries, equipment, business, mineral rights or
other money or property of any kind (including belongings held
in safe deposit boxes) that have not been shown elsewhere on
the application? (Include assets set aside for an emergency or
to provide for your heirs.)
26.
NO
NO
YES
YES
Go to #27
Go to (b)
Go to #27
Go to (b)
(b) Give the following information:
HOW IS IT USED? (If not used now, when was it
last used and what is next planned use.)
DESCRIPTION OF PROPERTY
(If real property, include type and
size of structure, acreage or lot size, location.)
Item 1
Item 1
Item 2
Item 2
OWNER'S NAME
ESTIMATED CURRENT
MARKET VALUE
TAX ASSESSED
VALUE
AMOUNT OF
MORTGAGE PAYMENT
Item 1
$
$
$ $
Item 2
$
$ $
$
You You r Spo us e, If fi l in g
27. Have you sold, transferred title, disposed of or given away
any money or other
property,
including propert y or
money in
foreign countries, since the first moment of the filing date
month or within the 30 months prior to the filing date month?
YES
NO
YES
NO
(Go to (b)
Go to #28
Go to #28
Go to (b)
(b) Giv
e the following information:
OWNER'S NAME
DATE OF
DISPOSAL
DESCRIPTION OF PROPERTY
Item 1
Item 2
IF THE DATE OF DISPOSAL IS BEFORE 7/1/88 AND LESS THA N 24 MONTHS PRIOR TO THE MONTH OF
FILING OR IF THE DATE OF DISPOSAL IS AFTER 6/30/88, GO TO 27(c); OTHERWISE GO TO #28.
(c) Give the following about the information in 27(b):
RELATIONSHIP
TO OWNER
SOLD ON OPEN MARKET
NAME AND ADDRESS OF PURCHASER
OR RECIPIENT
YES
NO
Item 1
Item 2
DO YOU STILL OWN PART
OF THE PROPERTY
VALUE OF PROPERTY
AND/OR AMOUNT OF
CASH GIFT
SALES PRICE
OR OTHER
AGREEM ENT
ARE ADDITIONAL CONSIDERATIONS OR
PROCEEDS EXPECTED? EXPLAIN
YES
NO
FORM
SSA-8000-BK
(5-90)
Page 6
(a)
(a)
Item 1
$
Item 2
$
AMOUNT OWED
ON ITEM
(b)
OWNER'S NAME
DESCRIPTION
FOR WHOSE
BURIAL
RELATIONSHIP
TO YOU OR
SPOUSE
CURRENT
MARKET VALUE
(if applicable)
$
$
28.
You
Your Spo us e
YES NO
YES
NO
Have you acquired any resource since the first moment of
the filing date month?
Go to (b)
Go to (c)
Go to (b)
Go to (c)
Explain any ''Yes'' answer given in 28(a)
Your Spou s e
You
You
Your Spo us e
Has there been any increase or decrease in the value of
your resources since the first moment of the filing date
month?
YES NO
YES
NO
Go to #29Go to (d)
Go to (d)
Go to #29
(d) Explain any ''Yes'' answer given in 28(c)
You
Your Spo us e
You
Your Spo us e
Do you have any assets set aside for burial expenses such
as burial contracts, trusts, agreements, or anything else you
intend for your burial expenses? Include any assets men-
tioned in items #22 through #26 and item #28.
29.
NO YES NO
YES
Go to #30 Go to #30Go to (b)
Go to (b)
(b)
DESCRIPTION (Where appropriate, give
name and address of organization and
account/policy number)
VALUE
WHEN SET
ASIDE
(Month, Day, Year)
OWNER'S NAME
Item 1
$
Item 2
$
(c) Explanation:
Item 1
Item 2
You
Your Spo us e
30.
Do you own any cemetery lots, crypts, caskets, vaults, urns,
mausoleums
or other repositories for burial or any head-
stones or markers?
YES NO
YES NO
Go to #31
Go to (b)
Go to (b)
Go to #31
Page 7
FORM
SSA-8000-B K (5-90)
(a)
(b)
(c)
(a)
(a)
FOR WHOSE BURIAL
IS ITEM IRREVOCABLE?
WILL INTEREST EARNED OR APPRECIATION IN
VALUE REMAIN IN THE BURIAL FUND?
Item 1
YES NO YES Go to #30 NO Explain In (c)
Item 2
YES
NO
YES Go to #30
NO Explain In (c)
PART IV—INCOME—The q u es ti o n s i n t h i s s ec ti o n s p ec i fy ti m e p er i od .
Since the first moment of the filing date month, hav
e you
received or do you expect to receiv
e income in the next
14 months from any of the following sources?
YOUR SPOUSE
31.
YOU
NO
YES
NO
YES
FEDERA L BENEFITS:
Railroad Retirement
Veterans Administration (Based on need/not based on need)
Office of Personnel Management (Civil Serv
ice)
.
Military Pension, Special Pay, or Allowance
Black Lung
Bureau of Indian Affairs
Earned Income Tax Credits
STATE/L OCA L BENEFITS:
Unemployment Compensation
Workers' Compensation
State Disability
.
State or Local Pension
Aid to Families with Dependent Children
State or Local Assistance Based on Need
PRIVATE BENEFITS:
Insurance or Annuity Payments
MISCEL LA NEOUS:
Rental/Lease Income
Dividends/ Royalties
Alimony
Child Support
OTHER INCOME NOT PREVIOUSLY MENTIONED
.
(b) Give the following information for any ''Yes'' answer in 31 (a), otherwise go to #32.
PERSON
RE CEIVING
TYPE OF
INCOME
DATES EXPECTED
OR RECEIVED
SOURCE (Name/Address of Person,
Bank, Company, or Organization)
IDENTIFYING
NUMBER
AMOUNT
FREQUENCY
You
$
You
$
You
$
Your
Spou s e
$
$
$
From:
To:
To:
To:
To:
To:
To:
-
FORM
SSA-8000-BK (5-90)
Page 8
(a)
Social Security
Employer or Union Pension
Interest (bank accounts, stocks, CD's, etc.)
From:
From:
From:
From:
From:
Your
Spou s e
Your
Spou s e
32.
Since the first moment of the filing date month, have you
received or do you expect to receiv
e any clothing, meals, or
other gifts which are not cash?
33.
Ha ve you receive d wages since the first moment of the filing
date month through the current month?
You r Spo u s e
You
Total wages received (before any deductions) for each month:
Month(s)
Amounts
Month(s)
Amounts
You
Your
Sp ou se
Do you expect to receive any wages in the next
14 months?
Name and address of employer if different from 33(b)
(include telephone number and area code, if known)
You r Spo u s e
You
Give the following information.
HOW OFTEN
PAID
PAY DAY OR
DATE PAID
DATE LAST PAID
(Month, day, year)
AMOUNT WORKED PER
PAY PERIOD
RATE OF PAY
You
$
per
Your
Sp ou se
$
per
Do you expect any change in wage information provided in
33(f)?
Explain change:
You r Spo u s e
You
Have you been self-employed at any time since the beginning
of the taxable year in which the filing date month occurs or do
you expect to be self-employed in the current taxable year?
34.
Give the following information:
LAST YEAR'S:
THIS YEAR'S:
TYPE OF BUSINESS
GROSS
INCOME
NET
GROSS
INCOME
NET
DATES OF
SELF- EM PLOYMENT
INCOME
LOSS
INCOME
LOSS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
You
Yo ur
Sp ou se
FORM
SSA-8000-B K (5-90)
Page 9
YES
NO
YES
NO
Go to (b)
Go to (d)
Go to (b)
Go to (d)
You
You r Spo u s e
YES
NO
YES
NO
Go to #33
Go to #33
Explain in
Remarks and
go to #33
Explain in
Remarks and
go to #33
(a)
Name and Address of Employer
(include telephone number and area code, if known)
(b)
(c)
YES
NO
YES
NO
Go to (e)
Go to #34
Go to (e)
Go to #34
You
You r Spo u s e
YES
NO
YES
NO
Go to (h) Go to (34)
Go to (h)
Go to (34)
You
You r Spo u s e
YES
NO
YES
NO
Go to (b) Go to (35)
Go to (b)
Go to (35)
You
You r Spo u s e
(d)
(e)
(f)
(g)
(h)
(a)
(b)
$
IF YOU OR YOUR SPOUSE A RE DISABLED AND RECEIVE WA GES OR EXPECT TO RECEIVE WAGES OR ARE
SELF-EMPLOYED OR EXPECT TO BE SELF-EMPLOYED, ANSWER #35: OTHERWISE, GO TO #36.
35.
Do you have any special expenses related to your illness or
injury that you paid which are necessary for you to work?
IF YOU ARE FILING A S A CHILD, A ND YOU A RE EMPLOYED OR AGE 18-22 (WHETHER EMPLOYED OR NOT),
GO TO #36; OTHERWISE, GO TO #37.
36.
(a)
YES
Go to (d)
NO
Go to (b)
Have you been out of school for more than 4 calendar
months?
YES
Go to (c)
NO
Go to (c)
Do you plan to attend school regularly during the next
4 months?
Explain
absence in
Rem arks
and go to (d)
YES
NO
Go to #37
Give the following information:
NAME OF PERSON AT SCHOOL
WE MAY CONTACT
COURSE OF STUDY
NAME AND ADDRESS OF SCHOOL
DATES OF
ATTENDANCE
FROM
TO
NAME
HOURS ATTENDING
OR PLANNING TO
ATTEND:
PHONE
(include area code)
POTENTIAL ELIGIBILITY FOR OTHER BENEFITS/FOOD STAMPS/MEDICAL
A SSIS TANCE
YOU
YOUR SPOUSE
37.
Have you or a former spouse (or if you are filing as a child,
have you or your parents) ever:
YES
NO
YES
NO
Worked for a railroad?
Been in military serv
ice?
Worked for the Federal gov
ernment?
Worked for a State or local gov
ernment?
Worked for an employer or belonged to a union w ith a pension plan?
Done work that was covered under the Social Security system
or pension plan of a country other than the United States?
(b) Explain and include dates (if appropriate) for any "Yes" answer given in 37(a); otherwise go to #38.
YOU
YOUR SPOUSE
Page 10
FORM
SSA-8000-B K (5-90)
You
YES
NO
Go to #36
Describe in
Remarks and
go to #36
Your Spo us e
YES
NO
Go to #36
Describe in
Remarks and
go to #36
Ha ve you attended s ch ool regularly since the filing
date month?
(b)
(c)
(d)
( _ _ _ ) -
PART V—
(a)
(b)
(c)
NO
Go to (d)
(d)
NO
Go to (e)
— — —
/
— —
/
— — — —
Are you currently receiving food stamps or has a food stamp
application been filed for you within the past 60 days on
which there has not been a decision?
Do you wish to apply for food stamps?
YES
NO
YES
NO
38.
39.
Where thi s ap pl ic ati on is an appl ic ation fo r Titl e XIX under th e Soc ial Secu ri ty Act , I/w e un derst and that
If I/we refuse to assign my/our rights to medical support and payments for medical care from any
indivi dual or pr ivat e, g roup, o r gover nment health in surance, or refuse to cooperate in giving i nf or m a-
tion regarding any health insurance I/we may have, that the Social Security Administration cannot
determi ne w hether I am/w e are eligible fo r Medicaid and that I/w e mu st then ap ply f or Med icaid at t he
Med icaid agenc y. I/w e also unders tan d that
as a condition to become el igible for Medicaid, I/we must
cooper ate with the Medicaid agency in establishing paternity and in obtaining medical support and
payment s f r om t hi r d part y payer s.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, GO TO 39(b).
Do you agree to assign your rights (or the rights of anyone
for whom you can legally assign rights) to payments for
medical support and other medical care to the State Medi-
caid agency?
Do you, your spouse, parent or step-parent have any private,
group, or government health insurance that pays the cost of y our
medical care? (Do not include Medicare or Medicaid)
YES
NO
YES
NO
Do you have any unpaid medical expenses for the 3 months
prior to the filing date month?
NO
YES
NO
YES
PART VI—MISCELLANEOUS
ANSWER #40 ONLY IF YOU A RE REQUESTING BENEFITS ON BEHA L F OF SOMEONE EL SE; OTHERWISE, GO TO #41.
Your Social Security Number
40.
(a) Name of Person Requesting Benefits
Relationship to Claimant
Are you serving, or have y ou ever served, as representative payee
for anyone receiving a Social Security or Supplemental Security
Income benefit?
Does the claimant have a legal representative or a legal guardian
appointed by a court?
Give the following information about the legal representative or legal guardian:
Telephone Number
(Include
area code, if known)
Name Address
(h) Explain w hat led the court to appoint a legal representative or a legal guardian.
FORM
SSA-8000-B K (5-90)
Page 11
You
YES
NO
Go to (b)
Go to # 39
You r Sp ou s e if fi li ng
YES
NO
Go to (b)Go to #39
You
YES
NO
Go to #40
Go to (b)
Your Spous e i f fi li ng
YES
NO
Go to #40
Go to (b)
(a)
(b)
(a)
(b)
(c)
(f)
Are you the natural or adoptive parent with custody?
Do you wish to be selected as the claimant's
representative payee?
Have you ever been convicted of a felony ?
(g)
(
__ __ __
)
–
YES
YES
YES
YES
YES
NO
Go to #41
Explain in
Remarks
and go to
#41.
NO
Go to (f)
If you are applying
on behalf of a child
go to (c); other-
wise go to #41.
Go to (d)
Explain in Remarks
and go to (e)
Enter SSN's in
Remarks and
go to (f)
If you are NOT the
legal rep/guardian,
go to (g); other-
wise go to (h).
NO
(e)
