TN 4 (04-07)
The SSA-8000-BK contains a detachable "claims receipt" and "changes to report" (reporting
instructions) page which provides the applicant with:
Written acknowledgment that a claim for SSI has been filed;
An estimate of the anticipated processing time after all necessary information is
The procedure to follow if a decision is not reached within the estimated processing
Information about the Privacy Act, computer matching and the penalty provision for
not reporting timely;
Information about the burden estimate and the request for comments; and
A summary of the claimant's reporting responsibilities.
When the signed application is received, complete the "Receipt for Claim" and "Changes
to Report" and give/mail it to the applicant.
Follow procedures in GN 00201.015H.2. See the steps below for completing the receipt for the paper SSA-8000-BK.
Enter the name(s) and SSN(s) of the claimant(s) in the space provided on the form.
EXCEPTION: When a representative payee files the application, enter the representative payee's
name followed by the word "for" and the name(s) of the claimant(s).
Enter the date the claim is filed.
Enter the telephone number and address of the servicing FO.
Enter (in the blank underlined area of the narrative) the estimated number of days
it will take to hear from us. (An estimate of the number of days required for processing
may be based on regional or local guidelines.)
Explain the Paperwork/Privacy Act Notice and computer matching statements as well
as the burden estimate and request for comments (see GN 03360.015 and MSOM MSSICS 024.002).
Review the reporting responsibilities and answer any questions the applicant may have
about the requirements. Remind the applicant about the penalty provision for failure
to make a timely report.
Complete the "Changes to Report:"
Prechecked items--Discuss the information with all claimants.
Unmarked items--Discuss the information for each unmarked item as applicable to the claim and mark the appropriate block(s).
Tell the applicant that he/she should retain the "Changes to Report" page for later
It provides written acknowledgement for filing an SSI claim and explains how to contact
The reverse side provides the changes to report.
Follow procedures in GN 00201.015H. See the steps below for completing the receipt the paper SSA-8000-BK.
1 - 7
Follow steps 1 - 7 in SI 00604.120B.2.
Detach tear-off page and retain it.
Upon receipt of the signed application form, follow procedures in GN 00201.015H.2. Provide the applicant with a cover note explaining the following:
The "Receipt for Claim" is enclosed; and
Purpose and importance of the "Changes to Report;" and
He or she must report changes because changes can affect payment. Call or write to
the Social Security office identified on the "Receipt;".
GN 00201.015F.1.h, Application Signed by Attestation
MSOM MSSICS 024.002, Application Receipt and Reporting Responsibilities, MSSICS Printed
MSOM MSSICS 022.003, Application Summary for SSI Applications