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Form SSA-8000-BK (06-2019) UF Discontinue Prior Editions Social
Security Administration
Page 1 of 24 OMB No. 0960-0229
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)
Note: Social Security Administration staff or others who help
people apply for SSI will fill out this form for you.
I am/We are applying for Supplemental Security Income
and any federally administered state supplementation
under Title XVI of the Social Security Act, for benefits
under the other programs administered by the Social
Security Administration, and where applicable, for
medical assistance under Title XIX of the Social
Security Act.
Do Not Write in This SpaceDATE STAMP
Filing Date (MM/DD/YYYY)
Receipt Protective
SNAP-SSA/APP SNAP-Referred
Preferred LanguageWritten: Spoken:
TYPE OF CLAIM Individual Individual with Ineligible Spouse
Couple ChildChild with Parents
PART 1 - BASIC ELIGIBILITY - Answer the questions below
beginning with the first moment ofthe filing date month.
1. (a) First Name, Middle Initial, Last Name Sex Male
Female
Birthdate(MM/DD/YYYY)
Social Security Number
(b) Did you ever use any other names (including maiden name) or
any other Social Security Numbers?
YES Go to (c) NO Go to (d)
(c) Other Name(s) Other Social Security Number(s) used
(d) If you are also filing for Social Security Benefits, go to
#2; otherwise complete the following:
Parent 1's Name (s)
Parent 1's Other Name (s) (Including Name at Birth)
Parent 2's Name (s)
Parent 2's Other Name (s) (Including Name at Birth)
Go to #22. Applicant's Mailing Address (Number & Street,
Apt. No., P.O. Box, Rural Route)
City and State (U.S.)/State/Province/Region (Foreign) ZIP
Code/Postal Code County/Country
3. Claimant's Residence Address (If different from applicant's
mailing address)
City and State (U.S.)/State/Province/Region (Foreign) ZIP
Code/Postal Code County/Country
4. DIRECT DEPOSIT PAYMENT INFORMATION (FINANCIAL
INSTITUTION)
Routing Transit Number Account Number Checking
Savings
Enroll in Direct Express
Direct Deposit Refused
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Form SSA-8000-BK (06-2019) UF Page 2 of 24
5.(a) Are you married? YES Go to (b) NO Go to #6
(b) Date of marriage: (MM/DD/YYYY)
(c) Spouse's Name (First, middle initial, last)
Birthdate(MM/DD/YYYY)
Social Security Number
(d) Did your spouse ever use any other names (including maiden
name) or Social Security Numbers?
YES Go to (e) NO Go to (f)
(e) Other Name(s) Other Social Security Number(s) Used
(f) Are you and your spouse living together? YES Go to #6 NO Go
to (g)
(g) Date you began living apart : (MM/DD/YYYY)
(h) Address of spouse or name of someone who knows where spouse
is. (Complete only if spouse is age 65, blind or disabled.)
6. (a) Have you had any other marriages? If never married, check
this box
You YESGo to (b)
NO Go to 6(c)
Your Spouse, if filing YESGo to (b)
NOGo to 6(c)
(b) Give the following information about your prior marriages.
If there was more than one prior marriage, show the remaining
information in Remarks. Go to #7.
YOU YOUR SPOUSE
FORMER SPOUSE'S NAME (including maiden name)
BIRTHDATE(MM/DD/YYYY)
SOCIAL SECURITY NUMBER
DATE OF MARRIAGE(MM/DD/YYYY)
DATE MARRIAGE ENDED (MM/DD/YYYY)
HOW MARRIAGE ENDED
(c) Are you and another person living together in the same
household and presenting to others or the community as a married
couple?
YES If YES, provide the date holding out began , then go to
(d)*
NO Go to #7
(d) Other person's Name (First, middle initial, last) Other
person's Social Security Number
*Use SSA-4178 to develop the holding out relationship.
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Form SSA-8000-BK (06-2019) UF Page 3 of 24
7. If you are filing for yourself, go to (a); if you are filing
for a child, go to (e).
(a) Are you unable to work because of illnesses,injuries or
conditions?
You
YESGo to (b)
NO Go to #8
Your Spouse
YESGo to (b)
NO Go to #8
(b) Enter the date you became unable to work.(MM/DD/YYYY)
(MM/DD/YYYY)
(c) Are you blind or do you have low vision even with glasses or
contacts?
You YESGo to (d)
NO Go to (d)
Your Spouse YESGo to (d)
NO Go to (d)
(d) If you were unable to work because of illnesses, injuries,
or conditions before you were age 22, do you have a parent who is
age 62 or older, unable to work because of illnesses, injuries or
conditions, or deceased?
YES Parent's Name:
Social Security Number:
Address:
Parent's Name:
Social Security Number:
Address:
NO Go to #8
(e) When did the child become disabled?(MM/DD/YYYY)
Go to (f)
(f) Is the child blind or do they have low vision even with
glasses or contacts? YESGo to (g)
NO Go to (g)
(g) Does the child have a parent(s) who is age 62 or older,
unable to work because of illness, injuries, or conditions, or
deceased?
YES Parent's Name:
Social Security Number:
Address:
Parent's Name:
Social Security Number:
Address:
NO Go to #8
8. Birthplace City State Country (if other than the U.S.)
You
Your Spouse, if filing Go to #9
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Form SSA-8000-BK (06-2019) UF Page 4 of 24
9.Are you a United States citizen by birth?
You
YESGo to #15
NOGo to #10
Your Spouse, if filing
YESGo to #15
NOGo to #10
10.Are you a naturalized United States citizen? YES
Go to #15 NOGo to #11
YESGo to #15
NOGo to #11
11. (a) Are you an American Indian born outside the United
States?
YESGo to (b)
NO Go to (c)
YESGo to (b)
NO Go to (c)
(b) Check the block that shows your American Indian status.
You Your Spouse, if filing
American Indian born in CanadaGo to #15
American Indian born in CanadaGo to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe Go to #15
Member of a Federally recognized Indian Tribe;
Name of Tribe Go to #15
Other American IndianExplain in Remarks, then Go to (c)
Other American IndianExplain in Remarks, then Go to (c)
(c) Check the block below that shows your current immigration
status
You Your Spouse, if filing
Amerasian Immigrant Go to #12 Amerasian Immigrant Go to #12
AsyleeDate status granted: Go to #14
AsyleeDate status granted: Go to #14
Conditional EntrantDate status granted: Go to #14
Conditional EntrantDate status granted: Go to #14
Cuban/Haitian EntrantGo to #14
Cuban/Haitian EntrantGo to #14
Deportation/Removal WithheldDate: Go to #14
Deportation/Removal WithheldDate: Go to #14
Lawful Permanent ResidentGo to #12
Lawful Permanent ResidentGo to #12
Parolee for One YearGo to #14
Parolee for One YearGo to #14
RefugeeDate of entry: Go to #14
RefugeeDate of entry: Go to #14
Unknown/OtherExplain in Remarks, then Go to (d)
Unknown/OtherExplain in Remarks, then Go to (d)
(d) If you have status or have applied for status as the spouse,
child, or parent of a child of a US citizen or lawfully admitted
permanent resident alien, Go to #13; otherwise Go to #15.
12. If you are lawfully admitted for permanent residence:
(a) Date of Admission
You(MM/DD/YYYY)
Your Spouse(MM/DD/YYYY)
(b) Was your entry into the United States sponsored by any
person or promoted by an institution or group?
YES Go to (c)
NO Go to (d)
YES
Go to (c)
NO
Go to (d)
(c) Give the following information about the person,
institution, or group, then Go to (d):
Name
Address
Telephone Number
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Form SSA-8000-BK (06-2019) UF Page 5 of 24
12.
(d) What was your immigration status, if any, before adjustment
to lawful permanent resident?
You
Status:
(MM/DD/YYYY)
From:
To:
Your Spouse, if filing
Status:
(MM/DD/YYYY)
From:
To:
(e) If filing as an adult, did your parents ever work in the
United States before you were age 18?
You
YESGo to (f)
NOGo to #14
Your Spouse, if filing
YESGo to (f)
NOGo to #14
(f) Name and Social Security Number of parent(s) who worked.
Name Social Security Number
Name Social Security Number
13.
(a) Have you, your child or your parent, been subjected to
battery or extreme cruelty while in the United States?
You
YES
Go to (b)
NO
Go to #15
Your Spouse, if filing
YES
Go to (b)
NO
Go to #15
(b) Have you, your child, or your 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?
YES
Go to #14
NO
Go to #15
YES
Go to #14
NO
Go to #15
14.Are you, your spouse, or parent an active duty member or a
veteran of the armed forces of the United States?
YES
Explain in #60(b), then Go to #15
NO
Go to #15
YES
Explain in #60(b), then Go to #15
NO
Go to #15
15. (a) When did you first make your home in the United
States?
(MM/DD/YYYY) (MM/DD/YYYY)
(b) Have you lived outside of the United States since then?
YES
Go to (c)
NO
Go to #16
YES
Go to (c)
NO
Go to #16
(c) Give the dates of residence outside the United States.
(MM/DD/YYYY)
From:
To:
(MM/DD/YYYY)From:
To:
16. (a) Have you been outside the United States (the 50 states,
District of Columbia and Northern Mariana Islands) 30 consecutive
days prior to the filing date?
YES
Go to (b)
NO
Go to #17
YES
Go to (b)
NO
Go to #17
(b) Give the date (MM/DD/YYYY) you left the United States and
the date you returned to the United States.
Date Left:
Date Returned:
Date Left:
Date Returned:
IF YOU ARE FILING ON BEHALF OF YOUR CHILD, GO TO #17.IF YOU ARE
MARRIED AND YOUR SPOUSE IS NOT FILING FOR SUPPLEMENTAL SECURITY
INCOME AND YOU LIVED TOGETHER AT ANY TIME SINCE THE FIRST MOMENT OF
THE FILING DATE MONTH, GO TO #17; OTHERWISE GO TO #18.
Go to (e)
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Form SSA-8000-BK (06-2019) UF Page 6 of 24
17. (a) Is your spouse/parent the sponsor of an alien who is
eligible for supplemental security income?
YES Go to (b) No Go to #18
(b) Eligible Alien's Name Eligible Alien's Social Security
Number
Go to #18
18.(a) Do you have any unsatisfied felony warrants for your
arrest?
You
YES
Go to (b)
NO
Go to #19
Your Spouse, if filing
YES
Go to (b)
NO
Go to #19
(b) In which State or Country was this warrant issued?Name of
State/Country
Go to (c)
Name of State/Country
Go to (c)
(c) Was the warrant satisfied?
You YES
Go to (d)
NO
Go to #19
Your Spouse, if filing YES
Go to (d)
NO
Go to #19
(d) Date warrant satisfied(MM/DD/YYYY) (MM/DD/YYYY)
PART 2 - LIVING ARRANGEMENTS - The questions in this section
refer to the signature date.
19. Check the block which best describes your present living
situation:
HouseholdSince (MM/DD/YYYY)
Go to #24
Non-Institutional CareSince (MM/DD/YYYY)
Go to #22
InstitutionSince (MM/DD/YYYY)
Go to #20
Transient or homelessSince (MM/DD/YYYY)
Go to #37
INSTITUTION
20. Check the block that identifies the type of institution
where you currently reside, then Go to #21:
School
Hospital
Rest or Retirement Home
Nursing Home
Rehabilitation Center
Jail
Other (Specify)
21. Give the following information about the INSTITUTION:
(a) Name of institution:
(b) Date of admission:
(c) Date you expect to be released from this institution: Go to
#37
NON-INSTITUTIONAL CARE
22. Check the block that best describes your current residence,
then Go to #23:
Foster Home Group Home Other (Specify)
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Form SSA-8000-BK (06-2019) UF Page 7 of 2423. Give the following
information about your Noninstitutional Care:
(a) Name of facility where you live:
(b) Name of placing agency
Address
Telephone Number
(c) Does this agency pay for your room and board?
YES Go to #37
NO If NO, who pays?Go to #37
HOUSEHOLD ARRANGEMENTS
24. Check the block that describes your current residence, then
Go to #25:
House
Apartment
Room (private home)
Room (commercial establishment)
Mobile Home
Houseboat
Other (Specify)
25. Do you live alone or only with your spouse? YES Go to #27 NO
Go to #26
26. (a) Give the following information about everyone who lives
with you:
Name RelationshipPublic
Assistance
YES NO
Sex
M F
Birthdate
mm/dd/yy
Blind or Disabled
YES NO
If Under 22Married
YES NOStudent
YES NO
Social Security Number
If anyone listed is under age 22 and not married, Go to (b);
otherwise, Go to #27.
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Form SSA-8000-BK (06-2019) UF Page 8 of 2426. (b) Does anyone
listed in 26(a) who is under age 18, OR
between ages 18-22 and a student, receive income? YES Go to (c)
NO Go to #27
(c) Child Receiving Income Source and Type Monthly Amount
$
$
$
$
$
$
27. (a) Do you (or does anyone who lives with you) own or rent
the place where you live?
YES Go to #28 No Go to (b)
(b) Name of person who owns or rents the place where you
live
Address
Telephone Number
(c) If you live alone or only with your spouse, and do not own
or rent, Go to #37; otherwise, Go to #31.
28.
(a) Are you (or your living with spouse) buying or do you own
the place where you live?
YES Go to (c)
NoIf you are a child living with your parent(s) Go to (b);
otherwise Go to #29
(b) Are your parent(s) buying or do they own the place where you
live?
YES Go to (c) NO Go to #29
(c) What is the amount and frequency of the mortgage
payment?
Amount: $Frequency of Payment:
Go to (d)
(d) If you are a child living only with your parents, or only
with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living
alone or with your spouse, Go to #37; otherwise Go to #31.
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Form SSA-8000-BK (06-2019) UF Page 9 of 2429.
(a) Do you (or your living with spouse) have rental liability
for the place where you live?
YES Go to (d)
NoIf you are a child living with your parent(s) Go to (b);
otherwise Go to (c)
(b) Does your parent(s) have rental liability? YES Go to (d) NO
Go to (c)
(c) Does anyone who lives with you have rental liability for the
place where you live?
YES Give name of person with rental liability: Go to #30
NO Give name of person with home ownership: Go to #31
(d) What is the amount and frequency of the rent payment?
Amount: $Frequency of Payment: Go to #30
30. (a) Are you (or anyone who lives with you) the parent or
child of the landlord or the landlord's spouse? YES Go to (b) NO Go
to (c)
(b) Name of person related to landlord or landlord's spouse
Relationship
Name and address of landlord (include telephone number and area
code, if known):
(c) If you are a child living only with your parents, or only
with your parents and their other children who are subject to
deeming, or with others in a public assistance household, or living
alone or with your spouse, Go to #37.
31. (a) Does anyone living with you contribute to the household
expenses? (NOTE: See list of household expenses in #36)
YES Go to (b) NO Go to #32
(b) Amount others contribute: $ Go to #3232. (a) Do you eat all
your meals out? YES Go to #33 NO Go to (b)
(b) Do you buy all your food separately from other household
members:
YES Go to #33 NO Go to #33
33. Do you contribute to household expenses?
YES Average Monthly Amount: $ Go to #34 NO Go to #34
34. (a) Do you have a loan agreement with anyone to repay the
value of your share of the household expenses? YES Go to (b) NO Go
to #34(d)
(b) Give the name, address and telephone number of the person
with whom you have a loan agreement :
(c) Will the amount of this loan cover your share of the
household expenses?
YES Go to #37 NO Go to (d)
(d) If you contribute toward household expenses and you answered
"NO" to both 32(a) & (b), Go To #35. If you answered "YES" to
either 32(a) or 32(b), Go to #36.
If you do not contribute toward household expenses, go to
#37.
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Form SSA-8000-BK (06-2019) UF Page 10 of 2435. (a) Is part or
all of the amount in #33 just for food?
YES Give Amount: $ Go to (b) NO Go to (b)
(b) Is part or all of the amount in #33 just for shelter?
YES Give Amount: $ Go to #36 NO Go to #36
36. What is the average monthly amount of the following
household expenses:(Show average over the past 12 months unless you
have been residing at your present address less than 12months. If
so, show average for the months you have resided at your present
address.)
CASH EXPENSES AVERAGE MONTHLY AMOUNT
Food (complete only if #32(a) & (b) are answered NO) $
Mortgage or Rent $
Property Insurance (if required by mortgage lender) $
Real Property Taxes $
Electricity $
Heating Fuel $
Gas $
Sewer $
Garbage Removal $
Water $
TOTAL $ Go to #3737. (a) Does anyone who does NOT LIVE with you
pay for, or provide you or your household (if applicable), any of
your
food or shelter items?
YES Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NOGo to (b)
(b) Does anyone who does NOT LIVE with you give you, or your
household (if applicable), money to pay for any of your or your
household's food or shelter items?
YES Name of Provider (Person or Agency)
List of Items
Monthly Value: $
NOGo to #38
38.
(a) Has the information given in #19-37 been the same since the
first moment of the filing date month?
YES Go to (b)
No
Explain in Remarks, then Go to (b)
(b) Do you expect any of this information to change? YES
Explain in Remarks, then Go to #39
No Go to #39
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Form SSA-8000-BK (06-2019) UF Page 11 of 24
PART 3 - RESOURCES - The questions in this section pertain to
the first moment of the filing date month.
39.(a) Do you own or does your name appear, either alone or
with other people on any trust?
You YES
Go to (b)
NO
Go to #40
Your Spouse, if filing YES
Go to (b)
NO
Go to #40
(b) If you answered "YES" to (a), give the following
information:
Title of the TrustFunding type, i.e., self-
funded or third party funded alleged
Date established (MM/DD/YYYY)
Total alleged value
Specific assets contained within the trust, i.e., vehicles,
homes,
bank accounts, etc.
40. (a) Do you own, or does your name appear (alone or with any
other person's name) on the title of any vehicles (auto, truck,
motorcycle, camper, boat, etc.)?
You
YESGo to (b)
NOGo to #41
Your Spouse YESGo to (b)
NOGo to #41
(b) Owner's NameDescription
(Year, Make & Model)Used For
Current Market Value
Amount Owed
$ $
$ $
$ $
$ $
41. (a) Do you own, or does your name appear (alone or with any
other person's name) on any land, houses, buildings, real property,
property in foreign country, equipment, mineral rights, items in a
safe deposit box, assets set aside for emergencies or heirs, or any
other property of any kind that has not been shown anywhere else on
the application
You
YES
Go to (b) NO
Go to #42
Your Spouse
YES
Go to (b)
NO
Go to #42
(b) Describe the property (including size, address, and how it
is used. If the property is not used now, when was it last used? Do
you plan to use the property in the future?
Item #1
Item #2
Owner's NameEstimated
Current Market Value
Owed on Item
$ $
$ $
$ $
$ $
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Form SSA-8000-BK (06-2019) UF Page 12 of 2442. (a) Do you own,
or does your name appear on (either
alone or with any other person's name) any of the following
items?
You
YES NO
Your Spouse
YES NO
Cash at home, with you, or anywhere else
Financial Institution Accounts
Achieving a Better Life Experience (ABLE)
Checking
Savings
Credit Union
Christmas Club
Time Deposits/Certificates of Deposit
Individual Indian Money Account
Other (Including IRAs and Keough Accounts)
(b) If all the items in #42(a) are answered "NO", Go to #42(c).
For any "YES" answer, give the following information:
Owner's Name Name of Item ValueName & Address of Bank or
Other OrganizationIdentifyingNumber
$
$
$
$
(c) Do you give us permission to obtain any financialrecords
from any financial institution?
You YESGo to #43
NOGo to #43
Your Spouse, if filing YESGo to #43
NOGo to #43
43.(a) Do you own or does your name appear on any of the
following items:
You
YES NO
Your Spouse
YES NO
Stocks or Mutual Funds
Bonds (Including U.S. Savings Bonds)
Promissory Notes
Other items that can be turned into cash
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Form SSA-8000-BK (06-2019) UF Page 13 of 2443. (b) If all the
items in #43(a) are answered "NO", Go to #44. For any "YES" answer,
give the following information:
Owner's Name Name of Item ValueName & Address of Bank or
Other OrganizationIdentifyingNumber
$
$
$
$
44.(a) Do you own or are you buying any life insurance
policies?
You
YESGo to (b)
NOGo to #45
Your Spouse YESGo to (b)
NOGo to #45
(b) Owner's Name Name of InsuredName & Address of Insurance
Company
Policy Number
Policy (#1)
Policy (#2)
Policy (#3)
Face Value Cash Surrender Value Date of PurchaseDividends
YES NO
Accumu-lations
YES NO
Policy (#1)
Policy (#2)
Policy (#3)
(c) Loans Against Policy?
YES Policy Number:
Amount: $NO Go to #45
45. (a) Have you or your spouse acquired any assets since the
first moment of the filing date month? YES Go to (b) NO Go to
(c)
(b) Explain:
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Form SSA-8000-BK (06-2019) UF Page 14 of 2445. (c) Has there
been any increase or decrease in the value
of you or your spouse's resources since the first moment of the
filing date month?
YES Go to (d) NO Go to #46
(d) Explain:
46. (a) Do you (either alone or jointly with any other person)
own any:
You
YES NO
Your Spouse
YES NO
Life estates or ownership interest in an unprobated estate?
Items acquired or held for their value as an investment?
(b) Give the following information for any "Yes" answer in
#46(a); otherwise, Go to #47.
Owner's Name Name of Item Value Amount OwedName & Address of
Bank or
Other Organization
$ $
$ $
$ $
$ $
47.(a) Do you have any assets set aside for burial
expenses such as burial contracts, trusts, agreements, or
anything else you intend for your burial expenses? Include any
items mentioned in #39, #41-45, and #49.
You
YESGo to (b)
NOGo to #48
Your Spouse
YESGo to (b)
NOGo to #48
(b) DESCRIPTION (Where appropriate, give name & address of
organization and account/ policy number.)
ValueWhen Set Aside(MM/DD/YYYY)
Owner's Name
For Whose Burial Is Item Irrevocable?Will Interest Earned or
Appreciation in
Value Remain in the Burial Fund?
Item (#1) $
Item (#1) YES NO YESGo to #48
NOExplain in (c)
Item (#2) $
Item (#2) YES NO YESGo to #48
NOExplain in (c)
(c) Explanation
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Form SSA-8000-BK (06-2019) UF Page 15 of 2448.
(a) Do you own any cemetery lots, crypts, caskets, vaults, urns,
mausoleums, or other repositories for burial or any headstones or
markers?
You
YESGo to (b)
NOGo to #49
Your Spouse
YESGo to (b)
NOGo to #49
(b) Owner's Name Description For Whose BurialRelationship to You
or
Your SpouseCurrent Market
Value
$
$
$ Go to #49
49. (a) Have you or your spouse sold, transferred title,
disposed of or given away, any money or other property, (including
money or property in foreign countries), since the first moment of
the filing date month or within the 36 months prior to the filing
date month?
You
YES NO Go to (b)
Your Spouse
YES NO Go to (b)
(b) If you co-owned any money or property with another
person(s), did you or any co-owner sell, transfer, or give away any
co-owned money or property within the 36 months prior to the filing
date month?
YES NO YES NO
IF YOU ANSWERED "YES" TO (a) OR (b), GO TO (c). IF "NO" TO BOTH,
GO TO #50.
(c) Owner's/Co-Owner's Name Description of Property Date of
Disposal
Name and Address ofPurchaser or Recipient
Relationship to OwnerValue of Property and/or
Amount of Cash Gift
Sales Price or Other ConsiderationAre Other Consideration or
Proceeds Expected?
Explain.
Do You Still Own Part of the Property?
Sold on Open Market? Given Away?Traded for Goods/
Services?
Item (#1)
Item (#1)
Item (#1)
Item (#1) YES NO YES NO YES NO
Item (#2)
Item (#2)
Item (#2)
Item (#2) YES NO YES NO YES NO
Item (#3)
Item (#3)
Item (#3)
Item (#3) YES NO YES NO YES NO
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Form SSA-8000-BK (06-2019) UF Page 16 of 24
PART 4 - INCOME
50. (a) Since the first moment of the filing date month, have
you (or your spouse) received or do you (or your spouse) expect to
receive income in the next 14 months from any of the following
sources?
You
YES NO
Your Spouse
YES NO
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 Based on Need (Paid Directly or Indirectly as a
Dependent)
Veteran Payments Not Based on Need (Paid Directly or Indirectly
as a Dependent)
Other Income Based on Need
Social Security
Black Lung
Railroad Retirement Board Benefits
Office of Personnel Management (Civil Service)
Pension (Foreign Military, State, Local, Private, Union,
Retirement or Disability)
Military Special Pay or Allowance
Unemployment Compensation
Workers' Compensation
State Disability
Insurance or Annuity Payments
Dividends/Royalties
Rental/Lease Income Not from a Trade or Business
Alimony
Child Support
Other Bureau of Indian Affairs Income
Gambling/Lottery Winnings
Other Income or Support
-
Form SSA-8000-BK (06-2019) UF Page 17 of 2450. (b) Give the
following information for any block checked YES in #50(a);
otherwise, Go to #51
PersonReceiving
IncomeType of Income
AmountReceived
Frequency of Payment
DateExpected or
Received
Source (Name, Address of Person,Bank,
Organization, or Company)
IdentifyingNumber
$
$
$
IF YOU EVER RECEIVED SSI BEFORE, GO TO #51; OTHERWISE GO TO
#52.
51. Are any overpayments being collected from benefits you
receive from the Social Security Administration, 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?
You
YESExplain in Remarks,then Go to #52
NOGo to #52
Your Spouse
YESExplain in Remarks,then Go to #52
NOGo to #52
52.
Since the first moment of the filing date month, have you
received or do you expect to receive any meals or other gifts which
are not cash?
YESExplain in Remarks,then Go to #53
NOGo to #53
YESExplain in Remarks,then Go to #53
NOGo to #53
53. (a) Have you (or your spouse) received wages or sick pay
since the first moment of the filing date month through the current
month?
YESGo to (b)
NOGo to (e)
YESGo to (b)
NOGo to (e)
(b) Name and Address of Employer (include telephone number and
area code, if known)
You
Go to (c)Your Spouse
Go to (c)
(c)Date last worked(MM/DD/YYYY)
Date last paid(MM/DD/YYYY)
Date next paid(MM/DD/YYYY)
You
Your Spouse
(d) Total monthly wages received (before any deductions) Your
Amount
$
Your Spouse's Amount
$
(e) Do you (or your spouse) expect to receive any wages in the
next 14 months?
You
YESGo to (f)
NOGo to #54
Your Spouse
YESGo to (f)
NOGo to #54
-
Form SSA-8000-BK (06-2019) UF Page 18 of 2453. (f) Name and
address of employer if different from #53(b) (include telephone
number, if known)
You
Your Spouse
(g) Give the following information:
Rate of PayAmount Worked Per
Pay PeriodHow Often Paid
Pay Day or Date Paid
Date Last Paid(MM/DD/YYYY)
You
YourSpouse
(h) Do you expect any change in wage information provided in
#53(g)
You
YESGo to (i)
NOGo to #54
Your Spouse
YESGo to (i)
NOGo to #54
(i) Explain Change:
You
Your Spouse
54. (a) Have you been self-employed at any time since the
beginning of the taxable year in which the filing date month occurs
or do you expect to be self-employed in the current taxable
year?
You
YESGo to (b)
NOGo to #55
Your Spouse
YESGo to (b)
NOGo to #55
(b) Give the following information; then Go to #55
Date(s) Self-Employed Type of Business Last Year's:Gross
Income
$
Last Year's: Net Profit
$
Last Year's:Net Loss
$Date(s) Self-Employed Type of Business This Year's:
Gross Income
$
This Year's: Net Profit
$
This Year's:Net Loss
$55.
If you or your spouse are blind or disabled, do you have any
special expenses that you paid which are necessary for you to
work?
You
YESExplain in Remarks,then Go to #56
NOGo to #56
Your Spouse
YESExplain in Remarks,then Go to #56
NOGo to #56
-
Form SSA-8000-BK (06-2019) UF Page 19 of 2456. (a) Does your
spouse/parent who lives with you have to
pay court-ordered support? YES Go to (b) NO Go to NOTE
(b) Give amount and frequency of court-ordered support
payment.
Amount: $Frequency of Payment:
Go to (c)
(c) Give the following information about the person who receives
these payments:
Name:
Address:
NOTE: IF YOU ARE FILING AS A CHILD AND YOU ARE EMPLOYED OR AGE
18 - 22 (WHETHER EMPLOYEDOR NOT), GO TO #57; OTHERWISE, GO TO
#58.
57. (a) Have you attended school regularly since the filing date
month?
YES Go to (d) NO Go to (b)
(b) Have you been out of school for more than 4 calendar
months?
YES Go to (c) NO Go to (c)
(c) Do you plan to attend school regularly during the next 4
months?
YES Explain absence in Remarks and Go to (d)
NO Go to #58
(d) Name of School Name of School Contact
Phone Number
Dates of AttendanceFrom To
Hours Attending orPlanning to Attend
Course of Study
PART 5 - POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION
ASSISTANCE PROGRAM (SNAP)/MEDICAL ASSISTANCE/OTHER BENEFITS
58.(a) Are you currently receiving SNAP benefits (formerly
food stamps)?
You
YESGo to (b)
NOGo to (c)
Your Spouse, if filing
YESGo to (b)
NOGo to (c)
(b) Have you received a recertification notice within the past
30 days?
YESGo to (e)
NOGo to #59
YESGo to (e)
NOGo to #59
(c) Have you filed for SNAP in the last 60 days? YESGo to
(d)
NOGo to (e)
YESGo to (d)
NOGo to (e)
(d) Have you received an unfavorable decision? YESGo to (e)
NOGo to #59
YESGo to (e)
NOGo to #59
(e) If everyone in the household receives or is applying for
SSI, Go to (f); otherwise Go to #59.
(f) May I take your SNAP application today? YESGo to #59
NOExplain in (g)
YESGo to #59
NOExplain in (g)
(g) Explanation:
-
Form SSA-8000-BK (06-2019) UF Page 20 of 2459. You may be
eligible for Medicaid. However, you must help your State identify
other sources that pay for medical
care. Also, you must give information to help the State get
medical support for any child(ren) who is your legal
responsibility. This includes information to help the State
determine who a child's parent is. If you want Medicaid, you must
agree to allow your State to seek payments from sources, such as
insurance companies, that are available to pay for your medical
care. This includes payments for medical care for you or any person
who receives Medicaid and is your legal responsibility. The State
cannot provide you Medicaid if you do not agree to this Medicaid
requirement. If you need further information, you may contact your
Medicaid Agency.
IN STATES WITH AUTOMATIC ASSIGNMENT OF RIGHTS LAWS, Go to
(b).
(a) Do you agree to assign your rights (or the rights of anyone
for whom you can legally assign rights) to payments for medical
support and other medical care to the State Medicaid agency?
You
YESGo to (b)
NOGo to #60
Your Spouse, if filing
YESGo to (b)
NOGo to #60
(b) Do you, your spouse, parent or stepparent have any private,
group, or governmental health insurance that pays the cost of your
medical care? (Do not include Medicare or Medicaid.)
YESGo to (c)
NOGo to (c)
YESGo to (c)
NOGo to (c)
(c) Do you have any unpaid medical expenses for the 3 months
prior to the filing date month?
YESGo to #60
NOGo to #60
YESGo to #60
NOGo to #60
60. (a) Have you ever worked under the U.S. Social Security
System?
YES Go to (b) NO Go to (b)
(b) Have you, your spouse, or a former spouse (or parent if you
are filing as a child) ever:
You
YES NO
Your Spouse/Parent
YES NO
Filed forBenefits
YES NO
Worked for a railroad
Been in military service
Worked for the Federal Government
Worked for a State or Local Government
Worked for an employer with a pension plan
Belonged to union with a pension plan
Worked under a Social Security system or pension plan of a
country other than the United States?
(c) Explain and include dates for any "Yes" answer given in #14
or #60(a); otherwise Go to #61.
You
Your Spouse, if filing/Your Parent, if filing as a child:
PART 6 - MISCELLANEOUS - (Answer #61 ONLY IF YOU ARE APPLYING ON
BEHALF OF SOMEONE ELSE: OTHERWISE GO TO #62.
61. (a) Name of Person/Agency Requesting Benefits.
Relationship to Claimant Your Social Security Number(or EIN)
(b) If SSA determines that the claimant needs help managing
benefits, do you wish to be selected representative payee?
YES NO(Explain in Remarks)
(c) Have you ever served as a representative payee for a Social
Security beneficiary or SSI claimant?
YES NOGo to #62
-
Form SSA-8000-BK (06-2019) UF Page 21 of 24PART 7 - REMARKS -
(You may use this space for any explanations. Enter the item number
before each
explanation. If you need more space, use a signed form
SSA-795.)
-
Form SSA-8000-BK (06-2019) UF Page 22 of 24
PART 8 - IMPORTANT INFORMATION AND SIGNATURES
62. IMPORTANT INFORMATION - PLEASE READ CAREFULLY • Failure to
report any change within 10 days after the end of the month in
which the change occurs could result in a penalty deduction. • The
Social Security Administration will check your statements and
compare its records with records from other State and Federal
agencies, including the Internal Revenue Service, to make sure you
are paid the correct amount. • We have asked you for permission to
obtain, from any financial institution, any financial record about
you that is held by the institution. We will ask financial
institutions for this information whenever we think it is needed to
decide if you are eligible or if you continue to be eligible for
SSI benefits. Once authorized, our permission to contact financial
institutions remains in effect until one of the following
occurs:
(1) you or your spouse notify us in writing that you are
canceling your permission,(2) your application for SSI is denied in
a final decision,(3) your eligibility for SSI terminates, or(4) we
no longer consider your spouse's income and resources to be
available to you.
If you or your spouse do not give or cancel your permission you
may not be eligible for SSI and we may deny your claim or stop your
payments.
63. I declare under penalty of perjury that I have examined all
the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly gives a false statement about
a material fact in this information, or causes someone else to do
so, commits a crime and may be subject to a fine or
imprisonment.
Your Signature (First name, middle initial, last name) (Sign in
ink.) Date (MM/DD/YYYY)
Telephone Number(s) where we can contact you during the day:
Spouse's Signature (Sign only if applying for payments.) (First
name, middle initial, last name) (Sign in ink.)
64. If you are blind or visually impaired, check the type of
mail you want to receive from us.
Standard notice First Class
Standard notice First-Class with a follow-up phone call
Standard notice & data CD by First-Class
Standard notice Certified
Standard & Braille notices by First-Class
Standard & large print notices
Standard notice & audio CD
65. WITNESS
Your application does not ordinarily have to be witnessed. If,
however, you have signed by mark (X), two witnesses to the signing
who know you, must sign below giving their full address.
1. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)
2. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)
-
Form SSA-8000-BK (06-2019) UF Page 23 of 24
RECEIPT FOR YOUR CLAIM FOR SUPPLEMENTAL SECURITY INCOME
Name Social Security Number Date
Name Social Security Number Date
If you have a question or something to report call: Social
Security Office you may visit or mail your request to:
For general information about Social Security, visit our website
at www.socialsecurity.gov on the Internet.
We will process your application for Supplemental Security
Income as quickly as possible. If you have trouble getting any
information or records we have asked for, please contact us and we
will help you.
You should hear from us within _____ days after you have given
us all the information we requested. Some claims may take longer if
additional information is needed. If you do not get a check or
notice of determination within that time, please get in touch with
us.
Privacy Act Statement Collection and Use of Personal
Information
Section 1631(e) of the Social Security Act, as amended, allows
us to collect this information. Furnishing us this information is
voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely
decision on a claim for Supplemental Security Income (SSI) or could
result in the loss of benefits.
We will use the information to determine SSI eligibility and to
calculate SSI payment amounts. We may also share your information
for the following purposes, called routine uses:
• To third party contacts, where necessary, to establish or
verify information provided by representative payees or payee
applicants; and
• To State agencies, to enable them to assist in the effective
and efficient administration of the SSI program.
In addition, we may share this information in accordance with
the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other
records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts
under these programs.
A list of additional routine uses is available in our Privacy
Act System of Records Notices (SORN) 60-0089, entitled Claims
Folders System, as published in the Federal Register (FR) on April
1, 2003, at 68 FR 15784, and 60-0103, entitled SSI Record and
Special Veterans Benefits, as published in the FR on January 11,
2006, at 71 FR 1830. Additional information, and a full listing of
all our SORNs, is available on our website at
www.ssa.gov/privacy.
Paperwork Reduction Act StatementThis information collection
meets the requirements of 44 U.S.C. § 3507, as amended by section 2
of the PaperworkReduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and
Budget control number. We estimate that it will take about 40
minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local Social Security office
through SSA’s website at www.socialsecurity.gov. Offices are also
listed under U. S. Government agencies in your telephone directory
or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the
completed form.
REPORTING RESPONSIBILITIES
The amount of a Supplemental Security Income (SSI) check is
based on the information told to us. You must tell Social Security
every time there is a change-while we process your application AND
if you start receiving SSI. Remember, a change may make the SSI
monthly payment bigger or smaller. Report changes in income of your
ineligible spouse or child who lives with you or your sponsor or
sponsor's spouse, if you are an alien. You must also report changes
in the things of value that these people own. You must also report
changes in income, school attendance and marital status of
ineligible children who live with you. You must tell us about any
change within 10 days after the month it happens. If you do not
report changes, we may have to take as much as $25, $50, or $100
out of future checks.
HOW TO REPORTYou may make your reports: • By telephone at the
telephone number shown above or call us toll free at 1-800-772-1213
(TTY 1-800-325-0778)
or• In person or • By mail at the address shown above.
-
Form SSA-8000-BK (06-2019) UF Page 24 of 24
CHANGES TO REPORT
WHERE YOU LIVE - You must report to Social Security if:• You
move.
• You (or your spouse) leave your household for acalendar month
or longer. (For example, you enter ahospital or visit a
relative.)
• You are admitted to (for a calendar month or longer),or
released from, a hospital or nursing home, jail,prison, or other
correctional facility or other institution.
• You leave the United States for 30 consecutive days.
• You are no longer a legal resident of the UnitedStates
HOW YOU LIVE - You must report to Social Security:• If anyone
moves into or out of your household.
• If the amount of money you pay toward householdexpenses
changes.
• Births and deaths of any people with whom you live.• Your
spouse or former spouse dies.
• Your marital status changes: - You get married, separated,
divorced, or your marriage is annulled. - You begin living with
someone as a married couple.
INCOME - You must report to Social Security if you, your
spouse/your parent(s):• Start to receive money (or checks or any
other type
of payment) from someone or someplace.
• Have a change in the amount of money you receive.• Begin to
receive child support payments or those
payments go up or down. • Win money from gambling or a
lottery.
• Start work or stop work.
• Earn more or less money. (Keep all paystubs andprovide them to
SSA when requested.)
• Become eligible for benefits other than SSI.
HELP YOU GET FROM OTHERS - You must report to Social Security
if:• The amount of help (money or food, or payment of
household expenses) you receive goes up or down.• Someone stops
helping you.• Someone starts helping you.
THINGS OF VALUE THAT YOU OWN - You must report to Social
Security if:• The value of things that you own goes over $2000
when you add them all together ($3000 if you aremarried and live
with your spouse).
• You sell or give any thing of value away.• You buy or are
given anything of value.
YOU ARE BLIND OR DISABLED - You must report to Social Security
if:• Your condition improves or your doctor says you
can return to work.• You go to work.
IF YOU ARE THE PARENT, STEPPARENT, OR REPRESENTATIVE PAYEE FOR A
CHILD UNDER 18 - A report to Social Security must be made if:
• There is a change in any income the child, his or her
parent(s), stepparent, or brother(s) or sister(s) receive.
• There is a change in the student status of the child's
brother(s) or sister(s).
• There is a change in his or her parents' or stepparents'
marriage, a change in value of anything they own, or a change in
their residence.
YOU ARE UNMARRIED AND UNDER AGE 22 - A report to Social Security
must be made if:• You start or stop school • You get married or
divorced • You start or stop working
YOUR IMMIGRATION STATUS CHANGES You must report any changes to
Social Security.
YOU ARE SELECTED AS A REPRESENTATIVE PAYEE - You must report to
Social Security if:• The person for whom you receive SSI checks
has
any changes listed above. (You may be held liableif you do not
report changes that could affect theSSI recipient's payment amount,
and he/she isoverpaid.)
• You will no longer be able or no longer wish to act asthat
person's representative payee.
FELONY OR ARREST WARRANT - You must report to Social Security if
you have a felony or arrest warrant for:
• Escape from custody • Flight to avoid prosecution or
confinement, or • Flight-Escape
Filing Date MMDDYYYY: Warrant State or Country You: Warrant
State or Country Spouse: Preferred Language Written: Preferred
Language Spoken: Receipt: OffProtective: OffSNAPSSAAPP:
OffSNAPReferred: OffIndividual: OffIndividual with ineligible
spouse: OffCouple: OffChild: Off24 Apt: Off24 Private Room: Off24
House: Off24 Mobile Home: Off24 Room commercial: Off24 Other: Off24
Houseboat: Off1 First Name Middle Initial Last Name: 1 Birthdate
MMDDYYYY: 1 Social Security Number: 1b Other Names or SSN: Off1c
Other Names: 1c Other Social Security Numbers used: 2 ZIP
CodePostal Code: 2 CountyCountry: 3 Claimants Residence Address If
different from applicants mailing address: 3 City and State
USStateProvinceRegion Foreign_2: 3 ZIP CodePostal Code: 3
CountyCountry: 4 Routing Transit Number: 4 Account Number: 4
Checking: Off4 Savings: Off4 Enroll in Direct Express: Off4 Direct
Deposit Refused: OffChild with parents: Off5a Married: Off5b Date
of marriage MMDDYYYY: 5c Birthdate: 5c SSN: 5d Other Name SSN Yes:
Off5d Other Name SSN No: Off5e Other Names: 5eOther Social Security
Numbers Used: 5f Living with spouse Yes: Off5f Living with spouse
No: Off5g Date you began living apart MMDDYYYY: 5h Address of
spouse or name of someone who knows where spouse is Complete only
if spouse is age 65 blind or disabled: 6a Never Married: Off6a
Other Marriages You Yes: Off6a Other Marriages You No: Off6a Other
Marriages Spouse Yes: Off6b Former Spouse Name Spouse: 6b Former
Spouse Name You: 6b Former Spouse DOB You: 6b Former Spouse DOB
Spouse: 6b Former Spouse SSN You: 6b Former Spouse SSN Spouse: 6b
Former Spouse Date Marriage You: 6b Former Spouse Date Marriage
Spouse: 6b Former Spouse Date Marriage Ended You: 6b Former Spouse
Date Marriage Ended Spouse: 6b Former Spouse How Marriage Ended
You: 6b Former Spouse How Marriage Ended Spouse: 6c Date holding
out began: 6c Living Together: Off6d Other person Name: 6d Other
person SSN: 7b Date Unable to Work You: 7b Date Unable to Work
Spouse: 6a Other Marriages Spouse No: Off7c Blind Spouse Yes: Off7c
Blind Spouse No: Off7d Parents Name: 7d Social Security Number: 7d
Address 1: 7d Address 2: 7d Address 3: 7d Parents Name_2: 7d Social
Security Number_2: 7d Address 1_2: 7d Address 2_2: 7d Address 3_2:
7e Date Child became disabled: 7g Child Parent Unable to Work Yes:
Off7g Child Parent Unable to Work No: Off7g Parents Name: 7g
Parents SSN: 7g Parents Address 1: 7g Parents Address 2: 7g Parents
Address 3: 7g Parents Name_2: 7g Parents SSN_2: 7g Parents Address
1_2: 7g Parents Address 2_2: 7g Parents Address 3_2: 8 Birth City
You: 8 Birth State You: 8 Birth City Spouse: 8 Birth State Spouse:
8 Birth Country You: 7a Unable to Work Spouse Yes: Off7a Unable to
Work Spouse No: Off7a Unable to Work You Yes: Off7a Unable to Work
You No: Off7f Child Blind Yes: Off7f Child Blind No: Off9 US
Citizen by Birth Spouse Yes: Off9 US Citizen by Birth Spouse No:
Off10 Naturalized US Citizen You Yes: Off10 Naturalized US Citizen
You No: Off10 Naturalized US Citizen Spouse Yes: Off10 Naturalized
US Citizen Spouse No: Off11 American Indian Born Out of US You Yes:
Off11 American Indian Born Out of US You No: Off11b American Indian
born in Canada: Off11b American Indian born in Canada_2: Off11b
Member of a Federally recognized Indian Tribe: Off11b Member of a
Federally recognized Indian Tribe_2: Off11b Other American Indian:
Off11b Other American Indian_2: Off11c Amerasian Immigrant: Off11c
Amerasian Immigrant_2: Off11c Asylee_1: Off11c Asylee_2: Off11c
Conditional Entrant: Off11c Conditional Entrant_2: Off11c
CubanHaitian Entrant: Off11c CubanHaitian Entrant_2: Off11c
DeportationRemoval Withheld: Off11c DeportationRemoval Withheld_2:
Off11c Lawful Permanent Resident: Off11c Lawful Permanent
Resident_2: Off11c Parolee for One Year: Off11c Parolee for One
Year_2: Off11c Refugee: Off11c Refugee_2: Off11c Unknown Other:
Off11c Unknown Other2: Off11 American Indian Born Out of US Spouse
Yes: Off11 American Indian Born Out of US Spouse No: Off12b Entry
into US Sponsored You Yes: Off12b Entry into US Sponsored You No:
Off12b Entry into US Sponsored Spouse Yes: Off12b Entry into US
Sponsored Spouse No: Off12c Name: 12c Address: 12c Telephone
Number: 12d Immigration Status You: 12d Immigration Status Spouse:
12d Immigration Status To Date You: 12d Immigration Status From
Date Spouse: 12d Immigration Status From Date You: 12d Immigration
Status To Date Spouse: 12e You Yes: Off12e You No: Off12e Spouse
Yes: Off12e Spouse No: Off12f Parent1 Name: 12f Parent1 SSN: 12f
Parent2 Name: 12f Parent2 SSN: 13a You Yes: Off13a You No: Off13a
Spouse Yes: Off13a Spouse No: Off13b You Yes: Off13b You No: Off13b
Spouse Yes: Off13b Spouse No: Off14 You Yes: Off14 You No: Off14
Spouse Yes: Off14 Spouse No: Off15a Date You: 15a Date Spouse: 15b
You Yes: Off15b You No: Off15b Spouse Yes: Off15b Spouse No: Off15c
From Date You: 15c To Date You: 15c From Date Spouse: 15c To Date
Spouse: 16a Spouse Yes: Off16a Spouse No: Off16b Date Left You: 16b
Date Returned You: 16b Date Left Spouse: 16b Date Returned Spouse:
17a Yes: Off17a No: Off17b Eligible Aliens Name: 17b Eligible
Aliens SSN: 16a You Yes: Off16a You No: Off18d Warrant Satisfied
Date You: 18d Warrant Satisfied Date Spouse: 18a You Yes: Off18a
You No: Off18a Spouse Yes: Off18a Spouse No: Off18c You Yes: Off18c
You No: Off18c Spouse Yes: Off18c Spouse No: Off19 Household: Off19
Household Since Date: 19 Non-Institution: Off19 NonInstitutional
Care Since Date: 19 Institution: Off19 Institution Since Date: 19
Transient or Homeless: Off19 Transient or homeless Since Date: 20
School: Off20 Hospital: Off20 Rest Retirement Home: Off20 Nursing
Home: Off20 Rehab Center: Off20 Jail: Off20 Other: Off12 Other
Specify: 21a Name of institution: 21b Date of admission: 21c
Expected Release Date: 22 Foster Home: Off22 Group Home: Off22
Other: Off22 Other Specify: 23a Name of facility: 23b Name of
placing agency: 23b Address: 23 Telephone Number: 23c Yes: Off23c
No: Off26a1 Name: 26a1Relationship: 26a2 Name: 26a3 Name: 26a4
Name: 26a5 Name: 26a6 Name: 26a2 Relationship: 26a3 Relationship:
26a4 Relationship: 26a5Relationship: 26a6 Relationship: 26a2
Birthdate: 26a1 Birthdate: 26a3 Birthdate: 26a4 Birthdate: 26a5
Birthdate: 26a6 Birthdate: 26a1 SSN: 26a2 SSN: 26a3 SSN: 26a4 SSN:
26a5 SSN: 26a6 SSN: 25 Yes: Off25 No: Off26a2 Public Assistance
Yes: Off26a3 Public Assistance Yes: Off26a4 Public Assistance Yes:
Off26a5 Public Assistance Yes: Off26a2 Public Assistance No:
Off26a3 Public Assistance No: Off26a4 Public Assistance No: Off26a5
Public Assistance No: Off26a1 Public Assistance Yes: Off26a1 Public
Assistance No: Off26a4 Male: Off26a5 Male: Off26a6 Male: Off26a1
Male: Off26a2 Male: Off26a3 Male: Off26a1 Female: Off26a2 Female:
Off26a3 Female: Off26a4 Female: Off26a5 Female: Off26a6 Female:
Off26a3 Blind or Disabled Yes: Off26a4 Blind or Disabled Yes:
Off26a5 Blind or Disabled Yes: Off26a6 Blind or Disabled Yes:
Off26a2 Blind or Disabled No: Off26a3 Blind or Disabled No: Off26a4
Blind or Disabled No: Off26a5 Blind or Disabled No: Off26a6 Blind
or Disabled No: Off26a1 Blind or Disabled No: Off26a1 Married Yes:
Off26a1 Married No: Off26a6 Married No: Off26a6 Married Yes:
Off26a2 Married Yes: Off26a2 Married No: Off26a3 Married Yes:
Off26a3 Married No: Off26a4 Married Yes: Off26a4 Married No:
Off26a5 Married Yes: Off26a5 Married No: Off26a1 Student No:
Off26a2 Student No: Off26a3 Student Yes: Off26a4 Student No:
Off26a5 Student Yes: Off26a5 Student No: Off26a1 Blind or Disabled
Yes: Off26a2 Blind or Disabled Yes: Off26a1 Student Yes: Off26a2
Student Yes: Off26a3 Student No: Off26a4 Student Yes: Off26a6
Public Assistance Yes: Off26a6 Public Assistance No: Off26a6
Student Yes: Off26a6 Student No: Off26c1 Child Receiving Income:
26c1 Source and Type: 26c1 Amount: 26c2 Child Receiving Income:
26c2 Source and Type: 26c2 Amount: 26c3 Child Receiving Income:
26c3 Source and Type: 26c3 Amount: 26c4 Child Receiving Income:
26c4 Source and Type: 26c4 Amount: 26c5 Child Receiving Income:
26c5 Source and Type: 26c5 Amount: 26c6 Child Receiving Income:
26c6 Source and Type: 26c6 Amount: 26b Anyone in 26a Income Yes:
Off26b Anyone in 26a Income No: Off27b Name: 27b Address: 27b
Telephone Number: 28a Buying or Own Yes: Off28a Buying or Own No:
Off28b Parents Buying or Rent Yes: Off28b Parents Buying or Rent
No: Off28c Frequency of Payment: 28c Mortgage Amount: 27a Own or
Rent Yes: Off27a Own or Rent No: Off29a Rental Liability No: Off29c
Anyone Rental Liability No: Off29c Name home ownership: 29c Name
Rental Liability: 29a Rental Liability Yes: Off29d Rent Frequency
of Payment: 29c Anyone Rental Liability Yes: Off29b Parents Rental
Liability Yes: Off29b Parents Rental Liability No: Off30a Parent or
Child of Landlord Yes: Off30a Parent or Child of Landlord No:
Off30b Name related to landlord: 30b Relationship to Landlord: 29d
Rent Amount: 30b Name and Address of Landlord: 31b Amount others
contribute: 31a Anyone Contribute Yes: Off31a Anyone Contribute No:
Off32a Eat meals out Yes: Off32a Eat meals out No: Off33 contribute
expenses Yes: Off33 contribute expenses No: Off33 Monthly Amount:
32b Buy food separately Yes: Off32b Buy food separately No: Off34a
Loan Agreement Yes: Off34a Loan Agreement No: Off34b Name Address
Phone: 34c Loan Cover share Yes: Off34c Loan Cover share No: Off35a
Just food Yes: Off35a Just food No: Off35a Amount for food: 35b
Just for Shelter Yes: Off35b Just for Shelter No: Off35 Amount for
shelter: 36 Amount Food: 36 Amount Mortgage/Rent: 36 Amount Prop
Ins: 36 Amount Prop Tax: 36 Amount Electricity: 36 Amount Heating:
36 Amount Gas: 36 Amount Sewer: 36 Amount Garbage: 36 Amount Water:
36 TOTAL: 037a Name of Provider Person or Agency: 37a List of
Items: 37a List of items2: 37a Value: 37b Name of Provider Person
or Agency: 37b List of Items: 37b List of Items2: 37b Value: 38a
Info same Yes: Off38a Info same No: Off37a Food shelter items Yes:
Off37a Food shelter items No: Off37b Money Yes: Off37b Money No:
Off38b Expect to change Yes: Off38b Expect to change: Off39a Trust
Spouse Yes: Off39a Trust Spouse No: Off39b Title of the Trust: 39b
Funding type: 39b Date established: 39b Total alleged value: 39b
Specific Assets: 39a Trust You Yes: Off39a Trust You No: Off40a
Vehicles You Yes: Off40a Vehicles You No: Off40a Vehicles Spouse
Yes: Off40a Vehicles Spouse No: Off40b1 Used For: 40b2 Current
Market Value: 40b2 Amount Owed: 40b1 Owners Name: 40b2 Owners Name:
40b2 Used For: 40b3 Owners Name: 40b3 Used For: 40b3 Current Market
Value: 40b3 Amount Owed: 40b4 Owners Name: 40b4 Used For: 40b1
Amount Owed: 40b1 Current Market Value: 40b1 Description: 40b2
Description: 40b3 Description: 40b4 Description: 41a Other property
Spouse Yes: Off41a Other property Spouse No: Off41b Item#1: 41b
Item#2: 41b Owners Name 1: 41b Owners Name 2: 41b Owners Name 3:
41b Owners Name 4: 41b Current Market Value 1: 41b Current Market
Value 2: 41b Current Market Value 3: 41b Current Market Value 4:
41b Amount Owed 1: 41b Amount Owed 2: 41b Amount Owed 3: 41b Amount
Owed 4: 41a Other property You Yes: Off41a Other property You No:
Off42a Cash You Yes: Off42a Cash Spouse No: Off42a Cash You No:
Off42a Cash Spouse Yes: Off42a Accounts You Yes: Off42a Accounts
You No: Off42a Accounts Spouse Yes: Off42a Accounts Spouse No:
Off42a ABLE You Yes: Off42a ABLE You No: Off42a ABLE Spouse Yes:
Off42a Checking You Yes: Off42a Checking You No: Off42a Checking
Spouse Yes: Off42a Checking Spouse No: Off42a Savings You Yes:
Off42a Savings You No: Off42a Savings Spouse Yes: Off42a Credit
Union You Yes: Off42a Credit UnionYou No: Off42a Credit UnionSpouse
Yes: Off42a Christmas Club You Yes: Off42a Christmas Club You No:
Off42a Christmas Club Spouse Yes: Off42a CD You Yes: Off42a CD You
No: Off42a CD Spouse Yes: Off42a CD Spouse No: Off42a Indian Acct
You Yes: Off42a Indian Acct You No: Off42a Indian Acct Spouse Yes:
Off42a Other You Yes: Off42a Other You No: Off42a Other Spouse Yes:
Off42a Other Spouse No: Off42c Permission Spouse Yes: Off42c
Permission Spouse: Off42c Permission Yes: Off42c Permission No:
Off43a Stocks You Yes: Off43a Stocks Spouse No: Off43a Stocks You
No: Off43a Stocks Spouse Yes: Off43a Bonds You Yes: Off43a Bonds
Spouse Yes: Off43a Bonds Spouse No: Off43a Promissary Notes You
Yes: Off43a Promissary Notes You No: Off43a Promissary Notes Spouse
Yes: Off43a Promissary Notes Spouse No: Off43a Other Spouse Yes:
Off43a Other Spouse No: Off43a Bonds You No: Off43b1 Owners Name:
43b1 Name Address of Bank: 43b1 Identifying Number: 43b2 Owners
Name: 43b2 Name of Item: 43b1 Name of Item: 43b1 Value of Item:
43b2 Value of Item: 43b3 Value of Item: 43b4 Value of Item: 43b2
Name Address of Bank: 43b3 Name Address of Bank: 43b4 Name Address
of Bank: 43b2 Identifying Number: 43b3 Identifying Number: 43b4
Identifying Number: 43b3 Owners Name: 43b3 Name of Item: 43b4 Name
of Item: 43b4 Owner's Name: 43a Other You Yes: Off43a Other You No:
Off44a Life Insurance Spouse Yes: Off44a Life Insurance Spouse No:
Off44b Policy 1: 44b Name of InsuredPolicy 1: 44b Policy
NumberPolicy 1: 44b Policy 2: 44b Name of InsuredPolicy 2: 44b Name
Address of Insurance CompanyPolicy 2: 44b Policy NumberPolicy 2:
44b Policy 3: 44b Name of InsuredPolicy 3: 44b Name Address of
Insurance CompanyPolicy 1: 44b Name Address of Insurance
CompanyPolicy 3: 44b Policy NumberPolicy 3: 44b Face Value Policy
1: 44b Cash Surrender Value Policy 1: 44b Date of PurchasePolicy 1:
44b Face Value Policy 2: 44b Cash Surrender Value Policy 2: 44b
Date of PurchasePolicy 2: 44b Face Value Policy 3: 44b Cash
Surrender Value Policy 3: 44b Date of PurchasePolicy 3: 44a Life
Insurance You Yes: Off44a Life Insurance You No: Off44b Dividends
Policy 1 Yes: Off44b Accumulations Policy 1 No: Off44b Dividends
Policy 1 No: Off44b Accumulations Policy 1 Yes: Off44b Dividends
Policy 2 Yes: Off44b Dividends Policy 2 No: Off44b Accumulations
Policy 2 Yes: Off44b Accumulations Policy 2 No: Off44b
Accumulations Policy 3 Yes: Off44b Accumulations Policy 3 No:
Off44b Dividends Policy 3 Yes: Off44b Dividends Policy 3 No: Off44c
Policy Number: 44c Amount: 45b Explain: 44c Loans Against Policy
Yes: Off44c Loans Against Policy No: Off45a Acquired Assets Yes:
Off45a Acquired Assets No: Off45d Explain: 45c Increase Decrease
Resources Yes: Off45c Increase Decrease Resources No: Off46a Life
Estates You Yes: Off46a Life Estates You No: Off46a Life Estates
Spouse Yes: Off46a Life Estates Spouse No: Off46a Items Held Spouse
Yes: Off46a Items Held Spouse No: Off46b1 Owners Name: 46b2 Owners
Name: 46b3 Owners Name: 46b4 Owners Name: 46b1 Name of Item: 46b2
Name of Item: 46b3 Name of Item: 46b4 Name of Item: 46b1 Value:
46b2 Value: 46b3 Value: 46b4 Value: 46b1 Amount Owed: 46b2 Amount
Owed: 46b3 Amount Owed: 46b4 Amount Owed: 46b1 Name Address of
Bank: 46b2 Name Address of Bank: 46b3 Name Address of Bank: 46b4
Name Address of Bank: 46a Items Held You Yes: Off46a Items Held You
No: Off47a Burial You Yes: Off47a Burial Spouse Yes: Off42b1 Owners
Name: 42b1 Name of Item: 42b1 Value: 42b1 Name Address of Bank:
42b1 Identifying Number: 42b2 Owners Name: 42b3 Owners Name: 42b4
Owners Name: 42b2 Name of Item: 42b3 Name of Item: 42b4 Name of
Item: 42b2 Value: 42b3 Value: 42b4 Value: 42b2 Name Address of
Bank: 42b3 Name Address of Bank: 42b4 Name Address of Bank: 42b2
Identifying Number: 42b3 Identifying Number: 42b4 Identifying
Number: 47b Item 1 Description: 47b Item 1 Value: 47b Item 1 When
Set Aside: 47b Item 1 Owners Name: 47b Item 2 Description: 47b Item
2 Value: 47b Item 2 When Set Aside: 47b Item 2 Owners Name: 47b
Item 1 For whose burial: 47a Burial Spouse No: Off47b Item 2 For
whose burial: 47b Item 1 Irrevocable Yes: Off47b Item 1 Irrevocable
No: Off47b Item 1 Interest Yes: Off47b Item 1 Interest No: Off47b
Item 2 Interest Yes: Off47b Item 2 Interest No: Off47c Explanation:
47b Item 2 Irrevocable Yes: Off47b Item 2 Irrevocable No: Off48a
Own burial repositories Spouse Yes: Off48a Own burial repositories
Spouse No: Off48b1 Owner's Name: 48b1 Description: 48b1 For Whose
Burial: 48b1 Relationship to You or Spouse: 48b1 Value: 48b2
Owner's Name: 48b3 Owner's Name: 48b2 Description: 48b3
Description: 48b2 For Whose Burial: 48b3 For Whose Burial: 48b2
Relationship to You or Spouse: 48b3 Relationship to You or Spouse:
48b2 Value: 48b3 Value: 48a Own burial repositories You Yes: Off48a
Own burial repositories You No: Off49a Sold Poperty You Yes: Off49a
Sold Poperty You No: Off49a Sold Poperty Spouse Yes: Off49a Sold
Poperty Spouse No: Off49a Co-Owner Sell You Yes: Off49a Co-Owner
Sell You No: Off49c1 Owner Name: 49c2 Owner Name: 49c3 Owner Name:
49c1 Description of Property: 49c2 Description of Property: 49c3
Description of Property: 49c1 Date of Disposal: 49c1 Relationship
to Owner: 49c1 Value: 49c2 Date of Disposal: 49c3 Date of Disposal:
49c2 Relationship to Owner: 49c3 Relationship to Owner: 49c3 Value:
49c2 Sales Price: 49c1 Sales Price: 49c3 Sales Price: 49c1 Other
Consideration: 49c2 Other Consideration: 49c3 Other Consideration:
49c1 Still Own: 49c2 Still Own: 49c3 Still Own: 49a Co-Owner Sell
Spouse Yes: Off49a Co-Owner Sell Spouse No: Off49c1 Sold Open
Market Yes: Off49c1 Sold Open Market No: Off49c1 Given Away Yes:
Off49c1 Given Away No: Off49c1 Traded Yes: Off49c1 Traded No:
Off49c2 Sold Open Market Yes: Off49c2 Sold Open Market No: Off49c2
Given Away No: Off49c2 Given Away Yes: Off49c2 Traded Yes: Off49c2
Traded No: Off49c3 Given Away Yes: Off49c3 Given Away No: Off49c3
Traded Yes: Off49c3 Traded No: Off49c3 Sold Open Market Yes:
Off49c3 Sold Open Market No: Off50a State Local You Yes: Off50a
State Local Spouse No: Off50a State Local You No: Off50a State
Local Spouse Yes: Off50a Refugee You Yes: Off50a Refugee You No:
Off50a Refugee Spouse Yes: Off50a Refugee Spouse No: Off50a TANF
You Yes: Off50a TANF You No: Off50a TANF Spouse Yes: Off50a TANF
Spouse No: Off50a GA BIA You Yes: Off50a GA BIA You No: Off50a GA
BIA Spouse Yes: Off50a GA BIA Spouse No: Off50a Disaster You Yes:
Off50a Disaster You No: Off50a Disaster Spouse Yes: Off50a Disaster
Spouse No: Off50a Veteran Not Need You Yes: Off50a Veteran Not Need
You No: Off50a Veteran Not Need Spouse Yes: Off50a Veteran Not Need
Spouse No: Off50a Social Security You Yes: Off50a Social Security
You No: Off50a Railroad You Yes: Off50a Railroad Spouse Yes: Off50a
Railroad Spouse No: Off50a Railroad You No: Off50a Social Security
Spouse Yes: Off50a Social Security Spouse No: Off50a Black Lung You
Yes: Off50a Black Lung You No: Off50a Black Lung Spouse Yes: Off50a
Black Lung Spouse No: Off50a Civil Service You Yes: Off50a Civil
Service You No: Off50a Civil Service Spouse Yes: Off50a Civil
Service Spouse No: Off50a Pension You Yes: Off50a Pension You No:
Off50a Pension Spouse Yes: Off50a Military You Yes: Off50a Military
You No: Off50a Military Spouse Yes: Off50a Unemployment You Yes:
Off50a Unemployment You No: Off50a Unemployment Spouse Yes: Off50a
Unemployment Spouse No: Off50a Workers' Comp You Yes: Off50a
Workers' Comp You No: Off50a Workers' Comp Spouse Yes: Off50a
Workers' Comp Spouse No: Off50a State Disability You Yes: Off50a
State Disability You No: Off50a State Disability Spouse Yes: Off50a
Insurance You Yes: Off50a Insurance You No: Off50a Insurance Spouse
Yes: Off50a Insurance Spouse No: Off50a Dividends You Yes: Off50a
Dividends You No: Off50a Dividends Spouse Yes: Off50a Rental Income
You Yes: Off50a Rental Income You No: Off50a Rental Income Spouse
Yes: Off50a Rental Income Spouse No: Off50a Alimony You Yes: Off50a
Alimony You No: Off50a Alimony Spouse Yes: Off50a Alimony Spouse
No: Off50a Child Support You Yes: Off50a Child Support You No:
Off50a Child Support Spouse Yes: Off50a Child Support Spouse No:
Off50a Other BIA You Yes: Off50a Other BIA You No: Off50a Other BIA
Spouse Yes: Off50a Other BIA Spouse No: Off50a Gambling You Yes:
Off50a Gambling You No: Off50a Gambling Spouse Yes: Off50a Gambling
Spouse No: Off50a Other Need You Yes: Off50a Other Need You No:
Off50a Other Need Spouse Yes: Off50a Other Need Spouse No: Off50a
Other You Yes: Off50a Other You No: Off50a Other Spouse Yes: Off50a
Other Spouse No: Off50b1 Person Receiving Income: 50b2 Person
Receiving Income: 50b3 Person Receiving Income: 50b1 Type of
Income: 50b2 Type of Income: 50b3 Type of Income: 50b1 Amount: 50b2
Amount: 50b3 Amount: 50b1 Frequency of Payment: 50b2 Frequency of
Payment: 50b3 Frequency of Payment: 50b1 Date Expected or Received:
50b3 Date Expected or Received: 50b2 Date Expected or Received:
50b1 Source: 50b2 Source: 50b3 Source: 50b1 Identifying Number:
50b2 Identifying Number: 50b3 Identifying Number: 51 Overpayments
You Yes: Off51 Overpayments You No: Off51 Overpayments Spouse Yes:
Off51 Overpayments Spouse No: Off52 Received meals or gifts You
Yes: Off52 Received meals or gifts You No: Off52 Received meals or
gifts Spouse Yes: Off52 Received meals or gifts Spouse No: Off53a
Received Wages You Yes: Off53a Received Wages You No: Off53a
Received Wages Spouse Yes: Off53a Received Wages Spouse No: Off53b
Employer You: 53b Employer Spouse: 53c Date last worked You: 53c
Date last worked Spouse: 53c Date last Paid You: 53c Date last Paid
Spouse: 53c Date Next Paid You: 53c Date Next Paid Spouse: 53d Your
Amount: 53d Spouse's Amount: 53e Expect Wages You Yes: Off53e
Expect Wages You No: Off53e Expect Wages Spouse Yes: Off53e Expect
Wages Spouse No: Off53f Employer You: 53f Employer Spouse: 53g Rate
You: 53g Rate Spouse: 53g Amount Worked Per Pay Period You: 53g
Amount Worked Per Pay Period Spouse: 53g How Often Paid You: 53g
How Often Paid Spouse: 53g Pay Day You: 53g Pay Day Spouse: 53g
Date Last Paid You: 53g Date Last Paid Spouse: 53h Expect change
You Yes: Off53h Expect change You No: Off53h Expect change Spouse
Yes: Off53h Expect change Spouse No: Off53i Explain Change You: 53i
Explain Change Spouse: 54a Self-Employed You Yes: Off54a
Self-Employed You No: Off54a Self-Employed Spouse Yes: Off54a
Self-Employed Spouse No: Off54b Type of Business Last Year: 54b
Type of Business This Year: 54b Dates Self Employed Last Year: 54b
Dates Self Employed This Year: 54b Last Year Gross: 54b Last Year
Profit: 54b Last Year Loss: 54b This Year Gross: 54b This Year
Profit: 54b This Year Loss: 55 Special Expenses Spouse Yes: Off55
Special Expenses Spouse No: Off55 Special Expenses You Yes: Off55
Special Expenses You No: Off56a Court-Ordered Support Yes: Off56a
Court-Ordered Support No: Off56b Amount: 56b Frequency: 56c
Recipient Name: 56c Recipient Address: 57a Attended School Yes:
Off57a Attended School No: Off57b Out of School Yes: Off57b Out of
School No: Off57d Name of School: 57d Name of School Contact: 57d
Phone Number: 57d To Date: 57d From Date: 57d Hours Attending: 57d
Course of Study: 57c Plan to attend School Yes: Off57c Plan to
attend School No: Off58a Currently SNAP Spouse Yes: Off58a
Currently SNAP Spouse No: Off58a Currently SNAP You Yes: Off58a
Currently SNAP You No: Off58b Recertification You Yes: Off58b
Recertification You No: Off58b Recertification Spouse Yes: Off58b
Recertification Spouse No: Off58c Filed You Yes: Off58c Filed You
No: Off58c Filed Spouse Yes: Off58c Filed Spouse No: Off58d
Unfavorable You Yes: Off58d Unfavorable You No: Off58d Unfavorable
Spouse No: Off58d Unfavorable Spouse Yes: Off58f Take SNAP App
Spouse No: Off58f Take SNAP App Spouse Yes: Off58g Explanation: 58a
Take SNAP App You Yes: Off58f Take SNAP App You No: Off59a Assign
your rights Spouse Yes: Off59a Assign your rights Spouse No: Off59a
Assign your rights You Yes: Off59a Assign your rights You No:
Off59b Health Insurance Spouse Yes: Off59b Health Insurance Spouse
No: Off59b Health Insurance You Yes: Off59b Health Insurance You
No: Off59c Unpaid Medical Expenses Spouse Yes: Off59b Unpaid
Medical Expenses Spouse No: Off59c Unpaid Medical Expenses You Yes:
Off59b Unpaid Medical Expenses You No: Off60a Worked under SS
System No: Off60a Worked under SS System Yes: Off60b Military You
Yes: Off60b Military You No: Off60b Military Spouse Yes: Off60b
Military Spouse No: Off60b Military Filed Yes: Off60b Military
Filed No: Off60b FedGovt You Yes: Off60b FedGovt You No: Off60b
FedGovt Spouse Yes: Off60b FedGovt Spouse No: Off60b FedGovt Filed
Yes: Off60b FedGovt Filed No: Off60b StateLocal You Yes: Off60b
StateLocal You No: Off60b StateLocal Spouse Yes: Off60b StateLocal
Spouse No: Off60b StateLocal Filed Yes: Off60b StateLocal Filed No:
Off60b Union You Yes: Off60b Union You No: Off60b Union Spouse Yes:
Off60b Union Spouse No: Off60b Union Filed Yes: Off60b Union Filed
No: Off60b OtherCountry You Yes: Off60b OtherCountry You No: Off60b
OtherCountry Spouse Yes: Off60b OtherCountry Spouse No: Off60b
OtherCountry Filed Yes: Off60b OtherCountry Filed No: Off60c
Explain You: 60c Explain Spouse: 61a Name: 61a Relationship: 61a
SSN: 60b Railroad You Yes: Off60b Railroad Filed No: Off60b
Railroad Spouse Yes: Off60b Railroad You No: Off60b Railroad Spouse
No: Off60b Railroad Filed Yes: Off61b RepPayee Yes: Off61b RepPayee
No: Off61b Served as RepPayee Yes: Off61b Served as RepPayee No:
OffPart 7 Remarks 1: Part 7 Remarks 2: Part 7 Remarks 3: Part 7
Remarks 4: Part 7 Remarks 5: Part 7 Remarks 6: Part 7 Remarks 7:
Part 7 Remarks 8: Part 7 Remarks 9: Part 7 Remarks 10: Part 7
Remarks 11: Part 7 Remarks 12: Part 7 Remarks 13: Part 7 Remarks
14: Part 7 Remarks 15: Part 7 Remarks 16: Part 7 Remarks 17: Part 7
Remarks 18: Part 7 Remarks 19: Part 7 Remarks 20: Part 7 Remarks
21: Part 7 Remarks 22: Part 7 Remarks 23: Part 7 Remarks 24: Part 7
Remarks 25: Part 7 Remarks 26: Part 7 Remarks 27: Part 7 Remarks
28: Part 7 Remarks 29: Part 7 Remarks 30: Part 7 Remarks 31: Part 7
Remarks 32: Part 7 Remarks 33: Part 7 Remarks 34: Part 7 Remarks
35: Part 7 Remarks 36: Part 7 Remarks 37: Part 7 Remarks 38: Part 7
Remarks 39: Part 7 Remarks 40: 63 Date: 63 Phone: 64 First Class:
Off64 First Class with phone call: Off64 Standard and CD by First
Class: Off64 Standard notice Certified: Off64 Standard and Braille
First Class: Off64 Standard large print notices: Off64 Standard
notice audio CD: Off65 Witness 1 Address: 65 Witness 2 Address: 24
Other Specify: 50a Veteran Need You Yes: Off50a Veteran Need You
No: Off50a Veteran Need Spouse Yes: Off50a Veteran Need Spouse No:
Off50a State Disability Spouse No: Off50a Dividends Spouse No: Off1
Sex: Off2 Mailing Address: 2 City and State: 1d Parent 2 Names: 1d
Parent 1 Names: 1d Parent 1 Other Names: 1d Parent 2 Other Name: 5c
Spouses Name: 7c Blind You Yes: Off7c Blind You No: Off7d Parent
unable to work Yes: Off7d Parent unable to work No: Off9 US
Citizen: Off12a Date of Admission You: 12a Date of Admission
Spouse: 42a ABLE Spouse No: Off42a Savings Spouse No: Off42a Credit
Union Spouse No: Off42a Christmas Club Spouse No: Off42a Indian
Acct Spouse No: Off47a Burial You No: Off50a Pension Spouse No:
Off50a Military Spouse No: Off60b Employer Pension You Yes: Off60b
Employer Pension You No: Off60b Employer Pension Spouse Yes: Off60b
Employer Pension Spouse No: Off60b Employer Pension Filed Yes:
Off60b Employer Pension Filed No: Off