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SSA-8000-BK -Non-medical application for SSI


Applicants for Supplemental Security Income (SSI) don't usually see this form. The interviewer uses it during the interview to accumulate the information needed to determine your eligibility. By completing a draft before your appointment, you not only help speed the interview, you also get a chance to answer all questions completely, not forget things you otherwise might, and get a chance to frame the answers in a manner most calculated to get a favorable response to your claim for SSI.

Even though SSA-8000-BK is probably the longest and most complicated form Social Security uses, it is advisable to have all the information requested on this form together prior to the interview.

Some of the directions in the form are complicated, such as: "If yes, go to XXX, if no, skip to XXX". Don't worry about making mistakes and answering too much. Focus instead on making sure you have all the information necessary to complete the form. Since this information is just for your working purposes, and the information is going to be entered into Social Security's computer during the interview, you can make notes right on the form, including "Xing" out those boxes that don't apply to you.

Don't be surprised if you have to do some digging in your records to answer all the questions and provide the documentation it requests.

Some of the questions may seem to be of no importance, but that is not the case. No question is unimportant to Social Security. Remember, SSI is a needs based program and is considered to be a "last resort" for financial assistance. Social Security is supposed to make sure not only that your income and resources are low enough to qualify for SSI, but that you don't qualify for other benefits. If it turns out you're entitled to another benefit such as spouse, children's, parent's benefits under a family member, then you will be given that. If the other benefit is low enough, you will be given a combination of that benefit plus SSI.

Assets and income belonging to spouses and parents is at times "deemed" to belong to you for purposes of determining SSI eligibility, so there are lots of questions about their financial status as well as about your own resources and income.

There are no right or wrong answers, only accurate ones. The penalties can be severe if you mislead Social Security into thinking you are eligible when you are not. At the least, Social Security will require a full repayment of all benefits.

You might consider the whole form as sort of a puzzle and that part of the interviewer's job is to find and ask questions that are raised when one part of the form does not seem to match other parts.

To see the form, click here. For assistance completing the questions, see:

Part I - Basic Eligiblity  

In addition to basic information about you such as name, date of birth, and Social Security number, Social Security wants to know about your spouse, ex-spouses, and parents as you may be eligible for benefits under one of them.

This part of the form also asks about your citizenship status since SSI is limited only to citizens and certain immigrants.  To learn more, see: SSI: Who Is Eligible For? 

Part II - Living Arrangements

In this part, Social Security examines what kind of housing you live in, who you live with and, how you are able to live where you do live. For example: It asks about your rent. If you say you live alone and your rent is $900 per month and in the income section you say you have no income, you will be asked questions about how the rent gets paid.

Housing can be considered income if you live rent-free, so Social Security wants to know about it. You will likely be asked if you are related to the landlord in case you are living and paying "below market" rent.

Question 30 asks about "rental liability." This is meant to find out who is legally responsible for the rental payments. That is usually the person named on the lease if there is one. If there is no lease, it is the person in whose name the property is rented.

Question 31 asks if you or your roommate are the parent or child of the landlord or the landlord's spouse. Those situations often result in income for SSI purposes  through below market rent levels. Social Security wants the name and address of the landlord in such cases. It is likely that Social Security will follow-up with that person.

Question 32 asks if anyone is helping you meet your living expenses by (a) asking about persons not living with you and (b) asking about persons who do live with you. 

Part III - Resources

Here is where Social Security obtains the details of your resources (assets) as well as those of your spousel.

Question 40 asks about all vehicles in which your name appears on the title, either solely or jointly with another. Social Security wants details such as:

  • Type of vehicle.
  • What the vehicle is used for.
  • Current value.
  • Any outstanding loan balance.

Keep in mind that one vehicle is exempt from resources for SSI purposes on the assumption you need it to go to the doctor. All other vehicles will be considered a resource in order to determine whether your not your resources are low enough to qualify for SSI benefits. (To learn more, see: SSI: Eligibility: Resources).

Question 41 asks about life insurance policies owned by you or your spouse. Note that Social Security wants each policy listed including:

  • Face value or face amount (the death benefit)
  • Accumulated cash value (basically the savings feature if the policy is permanent instead of term. To learn more, see: Life Insurance).
  • Date issued (the date the policy was issued)
  • Outstanding loans (against the policy.)

Only the cash value of policies with a face value exceeding $1,500 is a countable resource for SSI purposes. (To learn more, see: SSI: Eligibility: Resources).

NOTE: Most life insurance obtained through employment is "term" insurance which means there is no cash value so does not count as a resource.

Question 42 asks about life estates and property which someone left to you in their Will, but which has not yet been distributed. (A life estate permits you to live in a property for life, usually with obligations such as an obligation to keep the property in working order.) That will not be a factor in most cases.

Social Security also asks in the same question whether you own "Household or personal items worth more than $500 each." Note that the question is about "worth" - not "cost." It is also not about all your household or personal items lumped together. It is about the worth of each one.

Social Security does not usually consider as a resource personal property such as stereos, refrigerators, or jewelry unless there is a high value to them.

Question 43 asks about cash, cash accounts, and negotiable paper. You are obligated to report everything, whether there is a record of it or not. Be aware that this is the Social Security Administration doing the checking so anything with your Social Security number attached to it will likely be known by the agency.

Question #45 asks about real property in which you have an ownership interest. It also asks about contents of safe deposit boxes you rent or own that are not reported elsewhere. Be prepared to give details about all the property you report.

Question 47 asks about property you sold or otherwise disposed of in the 36 months prior to applying for SSI. The question is asked is because there are penalties for disposing of property for less than market value in order to qualify for SSI. To learn more, see: SSI: Eligibility: Transfer Of Assets (Resources).

Questions 48, 49 ask about resources set aside for burial expenses. Such resources usually are exempt from being counted as a resource. To learn more, see: SSI: Eligibility: Resources).

Part IV - Income  

This section asks about all possible sources of income you may be receiving. If your income exceeds the SSI benefit in your state, you are not eligible for SSI.

Keep in mind that income may consist of in-kind items in addition to actual money, for instance, housing, food, or assistance with bills.

Loans do not count as income since they must be paid back. To be considered a loan, there should be some documentation confirming the status as a loan. For Example: If the owner of the house where you live is not charging you rent, the value of what you are receiving is considered income. On the other hand, it's not income if there is a written loan agreement stating that your landlord is loaning you $XXX per month to cover the rent and it will be paid back either on a certain date or when a certain event occurs such as through life insurance proceeds.

Quesetion 50 asks about wages that you or your spouse are earning. While it is possible to be receiving some wages and still be eligible for SSI, if you are applying for SSI due to disability, any work will complicate the issue of whether or not you are disabled. To learn more, see: SSI: Eligibility: Income.

Part V - Potential Eligibility for Other Benefits

Question 58 Again, since SSI is considered the last resort for assistance, Social Security wants to see if you may be eligible for other benefits before granting you SSI benefits.

Question 59 applies to Medicaid which usually comes with the approval of SSI benefits.

  • You are required to agree to assign your rights to payents for medical care to your state's Medicaid agency. Unless you mark "Yes" on (a) you will not receive Medicaid with your SSI and must make application for it separately.
  • The form asks about other health insurance besides Medicare or Medicaid. Medicaid, like SSI, is the last resort for assistance so Social Security wants to know if you have other health insurance. Again, the penalties for not stating the truth which generates overpayments can be very severe when Social Security demands full repayment.
  • Social Security asks about recent, unpaid medical bills because it has the ability to backdate Medicaid eligibility three months to cover such unpaid bills.

Part VI - Miscellaneous 

Question 61 only applies if you are applying on behalf of someone else. See Representative Payee under Social Security Payments.

Receipt -The last page of the form is a receipt. Make sure it is completed and you receive it at the completion of the interview.

Note the remaining parts of the form that itemize factors that you must notify SSA about if they change while the application is in process.

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