TN 1 (10-89)
SI 01310.695 SSA-8010-BK - Authorization and Signature - Question 17
Explain to the person making the statement that signing form SSA-8010-BK provides authorization for the Social Security Administration to check statements and compare its records with records from other State and Federal agencies and contact employers for all SSI claims/redeterminations. Provide an opportunity for the individual(s) to object to or limit the authorization, but explain the specific effects that any authorization limitations may have. Do not photocopy this section of the form. Obtain authorization (form SSA-8510) as needed for third party contacts.
2. Agreement to Report Changes
Explain to the person(s) signing this form that their signature indicates they understand the importance of reporting all changes in income and resources, and that they agree to do so.
Complete the blocks on the “Reporting Responsibilities” part of the tear-off page with the name of the SSI claimant/recipient, his/her Social Security number, and the date of the statement.
At the bottom of the page, fill in the telephone number and the address of the Social Security office where the person may report any changes.
Cover the “Changes to Report” on the tear-off sheet with the person, and give him/her that page of the form to keep.
Ask the person reporting the income and resources to sign the SSA-8010-BK. See GN 00204.004 for situations when someone may sign for this individual. When an SSA-8010-BK is used for an ineligible child under age 18 who has income, a parent (or spouse of parent) may sign the form.
It is not necessary to get the signatures of both parents as long as the parent making the statement can provide information about the other parent's income and resources.
Have the sponsor of an alien sign the SSA-8010-BK if the alien is potentially or actually eligible for benefits.
If the person making the statement is not the person for whom income and resources are being reported, but completes the SSA-8010-BK as the eligible individual's representative payee, print the payee's name in the space provided below the signature block, and indicate his/her title or relationship to the deemor/ineligible child.