Form Ssa-8001-F5 - Application For Supplemental Security Income Page 2
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4(Use “Remarks” to explain any change between the first
PART II – LIVING ARRANGEMENTS TODAY –
moment of the filing date month and today.)
14.
Mark the box that describes where you live. If more than one type of residence is next to the box, put a circle around
the best description.
House, apartment, mobile home, room in
Room in a private home
a commercial establishment
Foster Home
Other (Specify) ____________________________
School, rehabilitation center, rest, retirement or
__________________________________________
nursing home, hospital, or jail
15.
Mark the box that describes with whom you live. If you live in a foster home or an institution, or if you are a transient,
do not answer but explain in “Remarks.”
Alone
Spouse / Parents and Children
Other People
(Show resources as of the first moment of the filing date month. Use “Remarks” to
PART III – RESOURCES –
explain any change since that time.)
If you own or your name or your spouse’s (parent’s) name(s) appear on any of the following items – either alone or
16.
with other people’s names, circle the item(s) and enter the total cash value of item(s) circled on each line.
Dollar Value
Dollar Value Spouse
Description
Yes No
You Own
or Parents Own
a. Cash at home, with you, or anywhere else
b. Savings, checking accounts, stocks, bonds
c. Insurance policies
d. Vehicles (cars, trucks, boats, motorcycles). How many ____?
e. Property other than the home you live in
f. Life estates or property you inherited
g. Other items that can be turned into cash
17.
Your Answer
Yes
No
Are any items listed in question 16 set aside to meet burial
expenses for you or your spouse (parents)? (If “Yes”, describe
Spouse (Mother’s) Answer
Yes
No
the item in “Remarks.”)
Father’s Answer
Yes
No
PART IV – INCOME –
(List all income received or expected to be received since the first moment of the filing date month.)
18.
List cash, checks, and direct payments to bank accounts you (your spouse / parents) received or expect to receive.
Include income from wages, self-employment, interest, social security, assistance based on need, VA, gifts,
pensions, and any other type of income. Note if current income will stop in the next 3 months. Also note here if
anyone pays any bills for you directly or gives you money to pay them.
Person Receiving
Frequency
Type of Income
Amount
Source of Income
Income
Received
$
$
$
$
$
$
$
Form SSA-8001-F5 (12-2002)
Page 2
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