Effective Dates: 12/19/2023 - Present Previous | Next

TN 50 (12-23)

SI 00604.001 Application For Supplemental Security Income, Form SSA-8000-BK

CITATIONS:

Regulations--20 CFR 416.301-416.335

A. Introduction

The Application for Supplemental Security Income provides the basis for establishing eligibility for SSI payments. The Modernized Supplemental Security Income Claims System (MSSICS) is the preferred method of taking SSI claims but there are occasions when a paper application must be taken. The SSA-8000-BK is the primary paper application form to apply for SSI payments.

The instructions in this section through SI 00604.130 use "claimant" and "applicant" as defined in GN 00201.005.

B. Description

1. General

The SSA-8000-BK is the long SSI application paper form. It includes a tear-off "Receipt for Claim" and "Changes to Report" page. The Spanish language version of this form is the SSA-8000-BK-SP.

2. Format

a. Related items

Related items are grouped together, where possible, and presented in a top-down decision logic format.

b. Questions/items

Questions/items are provided as guides and are not intended as all-inclusive. Special situations or information needed for a limited number of claims may require the completion of supplemental forms.

c. Answer blocks

Most answer blocks have printed "go to" instructions. The "go to" instructions direct you to the next required question/item.

C. Policy

1. Who May Complete

The SSA-8000-BK is not a self-help form. It is designed for completion by one of the following trained interviewers:

  1. a. 

    Claims representative (CR);

  2. b. 

    Field representative (FR);

  3. c. 

    Technical Expert (TE); or

  4. d. 

    Member of Social Security Administration (SSA) management.

See GN 00201.005G when an application is completed by a third party.

2. When To Use

a. Aged application

For an aged application, unless a clear technical denial is established at the time of filing. See SI 00602.001.

b. Simultaneous development

When simultaneous development is appropriate. See SI 00603.002.

c. Supplemental application

As a supplemental application when a medical allowance is received for a deferred development claim. See SI 00603.035.

d. Protecting an individual from loss of benefit rights

For protecting an individual from a loss of benefit rights to which there may be entitlement; i.e., Supplemental Nutrition Assistance Program (SNAP) benefits, Medicaid, Title II, etc.

e. Optional uses

Optional uses include:

  • •

    Deferred development - As a supplemental application to the SSA-8001-BK, the SSA-8000-BK is partially completed to document a questionable nondisability eligibility issue. See SI 00603.010.

  • •

    Abbreviated application - To better document a denial (e.g., deeming is involved) or when a SSA-8001-BK is unavailable at the time of the interview (e.g., contact station interview). See SI 00602.001C.4.

3. SSI Interviewing

The general information discussed during the preapplication interview guides you through the interview and eliminates confusion about what questions/items to answer. See GN 00203.001- GN 00203.090 and SI 00601.060 for interviewing procedures.

4. SSA-8000-BK As A Protective Filing

Naming a person on the SSA-8000-BK may be a protective filing. See SI 00601.020A.2.

5. Proper Applicant

A SSA-8000-BK must be signed by a proper applicant. (See GN 00201.015 for alternative signature methods.) However, if the claimant cannot sign their application and loss of benefits would occur, we will accept an application signed by a third party. See SI 00601.012 for the proper applicant policy.

D. Procedure

1. How To Use

  1. a. 

    Unless instructions specify otherwise, answer questions/items on the application as of the first day of the filing month. You may paraphrase questions in language geared to the applicant's level of understanding.

  2. b. 

    Go to the next question, item or instruction on the form where questions/items have no "Go To" instruction.

  3. c. 

    It is not necessary to mark "N/A" (not applicable) or line through questions/items which you are instructed to skip. However, doing so is left to the discretion of the interviewer.

  4. d. 

    Write "Unknown" if the applicant or claimant is uncertain about the information to provide. Do not assume that a blank represents a negative answer.

EXCEPTION: The social security number (SSN) block. When the SSN is unknown, follow procedures in SI 00604.016B.3.a. for face-to-face interviews and GN 00203.015 C.4 for teleclaims.

Use the mailing address including the city, State, and ZIP code when completing "address" information unless specified otherwise.

2. Obtain Queries

a. All SSI Claimants

Review queries for all SSI claimants during the preapplication discussion to confirm identity, determine if any application has been previously filed and to determine when a separate Title II application is required. See SI 00601.035.B.2.

b. Title II Application Previously Filed

If the claimant ever filed a Title II application (either on their own number or on someone else's earnings record), obtain an MBR under each claim number. Follow SI 00601.035C to determine if the claimant is entitled to a higher Title II benefit amount than they are currently receiving.

NOTE: Rely on SSA’s data when there is a discrepancy in the claimant’s allegation and SSA’s records. Experience has proven that claimants often cannot recall accurately the month or year of filing.

c. Online Queries Not Available

When it is not possible to obtain online queries before the interview is completed, obtain the queries prior to SSA-450SI input.

  • •

    Do not delay processing the application if an online query is not available.

  • •

    Obtain queries overnight or the next day.

  • •

    Associate them with the file.

Retain queries in the file through adjudication. See DI 11005.085 about forwarding queries to DDS when a prior claim was filed.

3. Use of Queries

The queries are used to decide the following claims-related issues.

a. Title II

  • •

    A separate Title II application must be taken unless an exception in SI 00601.035B.2 exists;

  • •

    Potential entitlement as an auxiliary or survivor on another should be explored;

b. Title XVI

If a Title XVI application was ever filed by, or on behalf of, the claimant, the interviewer must consider whether the:

  • •

    Claimant is still in an appeals period (see SI 04005.010 - SI 04005.015);

  • •

    Prior application can be reopened under the rules of administrative finality (see SI 04070.001 - SI 04070.010);

  • •

    Prior period of eligibility was suspended or terminated (see SI 02301.205);

  • •

    Claimant was overpaid SSI previously (see SI 02220.011 (TREBDET) and SI 02220.025 B.4. for overpayments and recovery and SM 01311.385 to carry forward overpayments from a prior record); and

  • •

    Claimant was overpaid Title XVI benefits and Title II benefits are being withheld via cross-program adjustment to collect the Title XVI overpayment.

c. Claimant Converted from a State Program

If the claimant was converted from a State program to SSI payment status in January 1974, consider the following:

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500604001
SI 00604.001 - Application For Supplemental Security Income, Form SSA-8000-BK - 12/19/2023
Batch run: 12/19/2023
Rev:12/19/2023