Section |
|
Latest Transmittal |
SI 00604.001 |
Application For Supplemental Security Income, Form SSA-8000-BK |
TN 50 12-23 |
SI 00604.002 |
Form SSA-8000-BK (Application for Supplemental Security Income (SSI): Exhibit |
TN 5 03-12 |
SI 00604.003 |
Preliminary Discussion Before Completing the SSA-8000-BK |
TN 4 04-07 |
SI 00604.005 |
Telephone (TEL) Block on Form SSA-8000-BK (Application for Supplementary Security
Income (SSI))
|
TN 6 05-12 |
SI 00604.006 |
Food Stamp-Social Security Administration/Application and Food Stamp (FS-SSA/APP and
FS)-Referred Blocks
|
TN 5 03-12 |
SI 00604.007 |
Unmarked Portion of Upper Right Corner of Page 1 |
TN 4 04-07 |
SI 00604.008 |
Filing Date Block |
TN 4 04-07 |
SI 00604.009 |
Preferred Language Block |
TN 4 04-07 |
SI 00604.010 |
Procedure for Type of Claim Section |
TN 55 12-23 |
SI 00604.015 |
Completing Part I (Basic Eligibility) of the SSA-8000-BK: General |
TN 5 03-12 |
SI 00604.016 |
Name, Sex, Birthdate, and SSN - Question 1(a) |
TN 12 04-20 |
SI 00604.017 |
Other Names and SSNs and Identifying Information - Question 1(b) - (d) |
TN 4 04-07 |
SI 00604.018 |
Marital Status: Question 5 |
TN 58 12-23 |
SI 00604.019 |
Prior Marriage(s) |
TN 10 08-19 |
SI 00604.020 |
Illnesses, Injuries, or Conditions (Blind or Disabled): Question 7 |
TN 66 01-24 |
SI 00604.022 |
Birthplace and U.S. Citizenship: Questions 8 Through 10 |
TN 5 03-12 |
SI 00604.023 |
Aliens Status: Question 11 |
TN 68 01-24 |
SI 00604.024 |
Alien Lawfully Admitted For Permanent Residence: Question 12 |
TN 49 12-23 |
SI 00604.025 |
Qualified Alien Status Based on Battery or Extreme Cruelty While in the U.S.: Question
13
|
TN 48 12-23 |
SI 00604.028 |
Qualified Alien Status Based on Active Military Duty: Question 14 |
TN 62 12-23 |
SI 00604.030 |
U.S. Residency: Question 15 |
TN 67 01-24 |
SI 00604.031 |
Presence in the U.S.: Question 16 |
TN 15 04-20 |
SI 00604.035 |
Alien Allocation: Question 17 |
TN 5 03-12 |
SI 00604.038 |
Fugitive Felons: Question 18 |
TN 5 03-12 |
SI 00604.045 |
Completing Part II (Living Arrangements) of the SSA-8000-BK: General |
TN 5 03-12 |
SI 00604.046 |
Where You Live: Question 20 |
TN 5 03-12 |
SI 00604.047 |
Institution: Question 21 |
TN 5 03-12 |
SI 00604.048 |
Institution Residence Information: Question 22 |
TN 5 03-12 |
SI 00604.049 |
Noninstitutional Care: Questions 22 and 23 |
TN 45 05-20 |
SI 00604.050 |
Household Arrangements: Question 24 |
TN 47 05-20 |
SI 00604.051 |
Living Alone or Only With Spouse: Question 25 |
TN 44 05-20 |
SI 00604.052 |
Household Composition: Question 26(a) |
TN 32 05-20 |
SI 00604.053 |
Children in Household Receiving Income: Question 26(b) and (c) |
TN 30 05-20 |
SI 00604.054 |
Rent-Free Shelter: Question 27 |
TN 54 12-23 |
SI 00604.055 |
Home Ownership: Question 28 |
TN 43 05-20 |
SI 00604.056 |
Rental Liability: Question 29 |
TN 25 05-20 |
SI 00604.057 |
Landlord/Tenant Relationship: Question 30 |
TN 27 05-20 |
SI 00604.058 |
Inside In-Kind Support and Maintenance (ISM) and Cash from Within Household: Question
31
|
TN 29 05-20 |
SI 00604.059 |
Separate Consumption and Separate Purchase of Food: Question 32 |
TN 52 12-23 |
SI 00604.060 |
Contributions to Household Expenses: Question 33 |
TN 42 05-20 |
SI 00604.061 |
Loan to Repay Share of Household Expenses: Question 34 |
TN 26 05-20 |
SI 00604.062 |
Earmarked Sharing: Question 35 |
TN 53 12-23 |
SI 00604.063 |
Household Operating Expenses: Question 36 |
TN 39 05-20 |
SI 00604.064 |
In-Kind Support and Maintenance (ISM) and Cash From Outside Of The Household: Question
37
|
TN 40 05-20 |
SI 00604.065 |
Changes In Living Arrangements: Question 38 |
TN 41 05-20 |
SI 00604.070 |
Completing Part III of the SSA-8000-BK (Resources) - General |
TN 4 04-07 |
SI 00604.071 |
Vehicles: Question 40 |
TN 51 12-23 |
SI 00604.072 |
Life Insurance: Question 44 |
TN 23 05-20 |
SI 00604.073 |
Life Estates, Unprobated Estates, and Other Items: Question 42 |
TN 5 03-12 |
SI 00604.074 |
Liquid Resources: Questions 42 and 43 |
TN 56 12-23 |
SI 00604.075 |
Other Property: Question 41 |
TN 61 12-23 |
SI 00604.077 |
Changes in Resources Since the Filing Date: Question 45 |
TN 34 05-20 |
SI 00604.078 |
Transfer of Resources: Question 49 |
TN 24 05-20 |
SI 00604.079 |
Burial Funds: Question 47 |
TN 36 05-20 |
SI 00604.080 |
Burial Space: Question 48 |
TN 35 05-20 |
SI 00604.085 |
Completing Part IV (Income) of the SSA-8000-BK: General |
TN 38 05-20 |
SI 00604.086 |
Income: Question 50 |
TN 57 12-23 |
SI 00604.087 |
Overpayment Collection From Other Benefits: Question 51 |
TN 5 03-12 |
SI 00604.088 |
In-Kind Support and Maintenance (ISM) to One Person or Other In-Kind Income: Question
52
|
TN 5 03-12 |
SI 00604.089 |
Wages: Question 53 |
TN 5 03-12 |
SI 00604.090 |
Self-Employment: Question 54 |
TN 5 03-12 |
SI 00604.091 |
Blind Work Expenses (BWE) and Impairment-Related Work Expenses (IRWE): Question 55 |
TN 19 05-20 |
SI 00604.092 |
Court Ordered Support: Question 56 |
TN 5 03-12 |
SI 00604.093 |
School Attendance: Question 57 |
TN 20 05-20 |
SI 00604.095 |
Completing Part V of the SSA-8000-BK (Potential Eligibility for Food Stamps/Medical
Assistance/ Other Benefits) - General
|
TN 4 04-07 |
SI 00604.096 |
Supplemental Nutrition Assistance Program (SNAP) (Formerly Known as Food Stamps):
Question 58
|
TN 8 04-19 |
SI 00604.097 |
Medical Assistance: Question 59 |
TN 69 01-24 |
SI 00604.098 |
Leads For Other Benefits: Question 60 |
TN 18 05-20 |
SI 00604.100 |
Completing Part VI (Miscellaneous) of the SSA-8000-BK: Question 61 |
TN 5 03-12 |
SI 00604.105 |
Completing Part VII of the SSA-8000-BK (Remarks) |
TN 11 02-20 |
SI 00604.108 |
Important Information: Item 62 |
TN 64 01-24 |
SI 00604.109 |
Signatures: General |
TN 60 12-23 |
SI 00604.111 |
Signature: Item 63 and 65 |
TN 65 01-24 |
SI 00604.113 |
Mailing Address: Question 2 |
TN 5 03-12 |
SI 00604.114 |
Claimant's Residence Address: Question 3 |
TN 63 12-23 |
SI 00604.116 |
Direct Deposit Information: Question 4 |
TN 5 03-12 |
SI 00604.118 |
Blind or Visually Impaired Notice Options: Question 64 |
TN 5 03-12 |
SI 00604.119 |
Witnesses - Question 65 |
TN 4 04-07 |
SI 00604.120 |
Completing the "Receipt For Claim" and "Changes To Report" Tear-Off Page |
TN 59 12-23 |
SI 00604.130 |
Filing For Medicaid Based on SSI |
TN 4 04-07 |