Form Ssa-8001-F5 - Application For Supplemental Security Income
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FORM APPROVED
SOCIAL SECURITY ADMINISTRATION
TEL
OMB NO. 0960-0444
Do not write in this space.
APPLICATION FOR SUPPLEMENTAL SECURITY INCOME
I am/We are applying for Supplemental Security
Income
and
any
federally
administered
State
supplementation under title XVI of the Social Security
DEFFERRED
ABAP
Act,
for
benefits
under
the
other
programs
FS-SSA APP
FS-REFERRED
administered by the Social Security Administration,
FILING DATE
and where applicable, for medical assistance under
Month, Day, Year
title XIX of the Social Security Act.
Actual
or
Protective
INDIVIDUAL WITH
TYPE OF CLAIM
COUPLE
INDIVIDUAL
CHILD
CHILD WITH PARENTS
INELIGIBLE SPOUSE
PART I – BASIC ELIGIBILITY
1.
First Name, Middle Name, Last Name
2. Birth
3. Sex
4. Social Security Number
(month,
day, year)
Male
Female
Spouse (Parent(s)) Name(s)
5.
6. Birth
7. Sex
8. Social Security Number(s)
(month,
day, year)
Male
Female
Other Names and Social Security Numbers you, your spouse (parents) used.
9.
a. Your Other Names (including Maiden Name)
Your Other Social Security Numbers
b. Spouse’s (Mother’s) Other Names (including Maiden Name)
Spouse’s (Mother’s) Other Social
Security Numbers
c. Father’s Other Names
Father’s Other Social Security
Numbers
11. Spouse’s Place of Birth (City and State or Foreign Country)
10.
Your Place of Birth (City and State or Foreign Country)
If you or your spouse (parents) are blind or disabled, note the date the impairment began and type of impairment.
12.
Date Impairment began
Type of impairment
Your Answer
Spouse’s (Mother’s) Answer
Father’s Answer
NOTE:
If you (and your spouse applying for benefits) were United States citizens at birth, go to question 14.
Spouse’s Answer, if filing
13.
Your Answer
a. Are you a naturalized United States citizen or lawfully
admitted for permanent residence in the United
YES
NO
YES
NO
States?
DATE
DATE
(month, day, year)
(month, day, year)
b. If you are lawfully admitted for permanent residence,
give the month / day / year of lawful admission.
NOTE: If the individual or spouse applying for benefits is not a citizen or lawfully admitted for permanent
residence, explain in “Remarks.”
Form SSA-8001-F5 (12-2002)
Page 1
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