Form Ssa-8001-F5 - Application For Supplemental Security Income Page 4
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4REMARKS (CONTINUED)
IMPORTANT INFORMATION – PLEASE READ CAREFULLY
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.
If you are disabled or blind, you must accept any appropriate vocational rehabilitation services offered to you by the State
agency to which we refer you.
PART VIII – SIGNATURES
I / We declare under penalty of perjury that I/we 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/our
knowledge.
22.
Your Signature (First name, middle initial, last name) (Write in ink)
Date (month, day, year)
Telephone number(s) at which you
may be contacted during the day
Spouse’s Signature (First name, middle initial, last name) (Write in ink)
23.
(Sign only if applying for payments.)
Applicant’s Mailing Address (Number and street, apt. no., P.O. box or rural route)
24.
City and State
ZIP Code
Enter name of county (if any) in
which you live
Claimant’s Residence Address (If different from applicant’s mailing address)
25.
City and State
ZIP Code
Enter name of county (if any) in
which the claimant lives
WITNESSES
26.
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 addresses.
1. Signature of Witness
2. Signature of Witness
Address (Number and Street, City, State, and ZIP Code)
Address (Number and Street, City, State, and ZIP Code)
Form SSA-8001-F5 (12-2002)
Page 4
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