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Form Ssa 8000

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Form SSA-8000 is also known as an Application for Supplemental Security Income (SSI). It is used by individuals who want to apply for SSI benefits. The applicant will need to answer all of the questions with as much information as possible. It may also be helpful to include medical documentation about the condition that caused the disability.

Form Ssa 8000
Form Ssa-521 › Form Ssa-454-Bk › Form Ssa-561-U2 ›

What is a SSA 8000?

A Form SSA 8000 is known as an Application for Supplemental Security Income. This form will be received and recorded by the Social Security Administration in the United States. The form is used to apply for SSI benefits, which can be given to someone who has a disability and thus has reduced income. This is a long form that has over 60 questions.
This form can be filled out for an individual, a couple, a child, or a child with their parents. These parties will need to list their personal identifying information as well as their financial information. After this, detailed information about the disabling medical condition is needed. Include as much detail as possible. You can also include medical documentation about your condition in order to provide the SSA with verifiable proof.

How to complete an SSA 8000 (Step by Step)

To complete a SSA-8000, you need to provide the following information:

  • Filing Date
  • Type of Claim: individual, individual with an ineligible spouse, couple, child, child with parents
  • Part I - Basic Eligibility - beginning with the first moment of the filing date month
    • Name 
    • Sex
    • Birthdate
    • Social security number
    • Whether you ever used any other names or any other social security numbers
    • Other names
    • Other social security numbers
    • Mother’s maiden name
    • Father’s name
    • Mailing address
    • Residence address
    • Direct deposit information
      • Routing transit number, account number, checking or savings account, enroll in direct express or direct deposit refused
    • Whether you are married
      • Date of marriage
      • Spouse’s name
      • Birthdate
      • Social security number
      • Whether your spouse ever used any other names or social security numbers
      • Whether you and your spouse are living together
      • Date you began living apart
      • Address of spouse or someone who knows where spouse is
      • Whether you have had any other marriages
      • If there was more than one former marriage, provide for each marriage: former spouse’s name, birthdate, social security number, date of marriage, date marriage ended, how marriage ended
      • If you are filing for yourself: whether you are unable to work because of illnesses, injuries, or conditions; date you became unable to work; list of illnesses, injuries or conditions
      • If you were unable to work because of illnesses, injuries, or conditions before you were 22, whether you have a parent who is age 62 or older and unable to work because of illnesses, injuries or conditions, or deceased
      • If you are filing for child, date the child became disabled; list of child’s debilitating illnesses, injuries or conditions; whether the child has a parent who is age 62 or older and unable because of illness, injuries, or conditions or deceased
      • Birthplace of you and your spouse
      • Whether you and your spouse are U.S. citizens by birth
      • Whether you and your spouse are naturalized U.S. citizens
      • Whether you are an American Indian born outside the United States
      • Indication of your American Indian status
      • Indication of your immigration status
      • If you are lawfully admitted for permanent residence,
        • Date of admission
        • Whether your entry was sponsored by any person or promoted by an institution or group
        • Any immigration status before an adjustment to lawful permanent resident
        • If filing as an adult, your parents ever worked in the United States before you were age 18
        • Whether you, your child, or parent have been subjected to battery or extreme cruelty while in the United States
        • Whether you, your child, or parent filed a petition with the Department of Homeland Security for a change in immigration status because of being subjected to battery or extreme cruelty
        • Whether you , your spouse, or parent is an active duty member or a veteran of the armed forces of the United States
        • Indicate when you first made your home in the United States
        • Indicate whether you lived outside of the United States since then
        • List dates of residence outside the United States
        • Whether you have been outside the United States 30 consecutive days prior to the filing date
        • Date you left the United States and the date you returned to the United States
        • Whether your spouse or parent is the sponsor of an alien who is eligible for supplemental security income
        • Whether you have any unsatisfied felony warrant for your arrest
        • Whether you have any unsatisfied Federal or State warrants for violating the conditions of probation or parole
  • Part II - Living Arrangements
    • Indicate you living situation
    • If an institution, indicate the name, date of admission, and expected release date
    • If non-institutional care, indicate name of facility, name of placing agency, address, telephone number, whether agency pays for your room and board
    • Household arrangements - describe your current residence
      • Indicate whether you live alone or only with your spouse
      • List every person who lives with you
        • Name
        • Relationship
        • Public assistance
        • Sex
        • Birthdate
        • Blind or disabled
        • If under 22, marital status and student status
        • Social security number
      • Indicate whether anyone who is listed for is under age 18 or between 18-22 and still a student receives income
        • Child receiving income
        • Source and type
        • Monthly amount
      • Whether you or anyone who lives with you owns or rents the place where you live
        • Name of the person who owns or rents the place where you live
        • Address
        • Phone number
      • Whether you or your spouse that you live with is buying or owns the place where you live
      • Whether you or your parents are buying or own the place where you live
        • Amount and frequency of mortgage payment
      • Whether you or your spouse that you live with have rental liability for the place where you live
        • Whether your parents have rental liability
      • Whether anyone who lives with you has rental liability for the place where you live
        • Frequency and amount of rent payment
      • Whether you or anyone who lives with you is the parent or child of the landlord or the landlord’s spouse
      • Whether anyone living with you contributes to the household expenses
        • Amount they contribute
      • Whether you eat all of your meals out
      • Whether you contribute to household expenses
        • Average monthly amount
      • Whether you have a loan agreement with anyone to repay the value of your share of the household expenses
      • Indicate average monthly amount of the following household expenses: food, mortgage or rent, property insurance, real property taxes, electricity, heating fuel, gas, sewer, garbage removal, water
      • Indicate if anyone who does not live for you pays for any of your expenses or gives your money to pay for your household expenses
  • Part III - Resources
    • Indicate any vehicle with your name on the title
    • Indicate any life insurance policies that you own
    • Indicate any ownership interest in life estate, unprobated estate, or items acquired for investment
    • Indicate whether you own or your name appears on any of the following: cahs, financial institution accounts, other 
    • Indicate whether you give the SSA permission to obtain any financial records and whether you own or your name appears on any stocks or mutual funds, bonds, promissory notes, trusts
    • Indicate whether your name appears on and land, house, buildings, or other types of property
    • Indicate whether you or your spouse has acquired assets since the first moment of the filing date month
    • Indicate whether there has been any increase or decrease in the value of you or your spouse’s resources since the first moment of the filing month
    • Whether you or your spouse sold, transferred title, or gave away any money or property since the first moment of the filing date month or within 36 months prior
    • If you co-owned any money or property with another, did you or your co-owner sell, transfer title, or give away any money or property since the first moment of the filing date month or within 36 months prior
    • Whether you have any money set aside for burial expenses
    • Whether you own any cemetery lots, crypts, caskets, vaults, etc.
  • Part IV- Income
    • Since the first moment of the filing date month, have you or your spouse received or do you expect to receive: a state or local assistance based on need, refugee cash assistance, temporary assistance for needy families, general assistance from the Bureau of Indian Affairs, disaster relief, veteran benefits, other need-based income, social security, black lung, railroad retirement board benefits, office of personnel management, pension, military special pay or allowance, unemployment compensation, state disability, insurance or annuity payments, rental/lease income, alimony, child support, gambling/lottery winnings
    • Indicate if overpayments are being collected from benefits received from the SSA, Railroad Retirement Board, Office of Personnel Management, Veterans' Affairs, Military Pensions, Military Special Pay Allowances, Black Lung, Workers' Compensation, or State Disability or Unemployment Benefits
    • Since the first moment of filing date month, whether you have received meals or gifts that were not cash
    • Whether you or your spouse received wages or sick pay since the first moment of the filing date month through the current month
    • Name and address of you and your spouse’s employer
    • Dates last worked, dates last paid, dates next paid
    • Total monthly wages received
    • Whether you or your spouse expect to receive any wages in the next 14 months
    • Rate of pay, amount worked per pay period, how often paid, pay day or date paid, dage last paid
    • Whether you expect any change in wage information 
    • Whether you have been self- employed at any time since the beginning of the taxable year in which the filing month occurs or whether you expect to be self-employed in the current taxable year
    • Whether you or your spouse is bling or disabled and you have any special expenses that you paid which are necessary for you to work
    • Whether your spouse/parent who lives with you has to pay court-ordered support
    • Whether you attended school regularly since the filing date month
  • Part V- Potential Eligibility for Food Stamps/Medical Assistance/Other Benefits
    • Whether you are currently receiving food stamps
    • Whether you received a recertification notice within the past 30 days
    • Whether you filed for food stamps in the last 60 days
    • Whether you received an unfavorable decision
    • Whether everyone in the household is receiving or is applying for SSI
    • Whether the SSAS may take your food stamp application today
    • Whether you agree to assign your rights to payments for medical support and other medical care to the state Medicaid agency
    • Whether you ever worked under the U.S. Social Security System
  • Part VI - Miscellaneous
    • Name of the person/agency requesting benefits
    • Relationship to claimant
    • SSN
    • Whether you wish to be selected representative payee
  • Part VII - Remarks
    • Any explanations needed from prior sections
  • Part VIII - Important Information and Signatures
    • Signature 
    • Date
    • Phone number
    • Spouse’s signature
    • Whether you are blind or visually impaired and require special mail service
    • Witnesses’ signatures and address
  • Receipt
    • Name
    • Social Security Number
    • Date

Download a PDF or Word Template

SSA-8000 Form 2012

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Form Ssa-521

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Form Ssa-454-Bk

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Form Ssa-561-U2

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Sample Form Ssa 8000

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Sample Form Ssa 8000

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