APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI) - Form SSA-8000-BK (01-2012) - Complete eligibility questions

Sep 19, 2026

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APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI) captures details needed to determine eligibility under Title XVI of the Social Security Act and related federal and state supplementation. The form collects applicant and claimant identity information, preferred language, claim type, filing date, and filing/receipt protections. It also requests mailing and residence addresses, direct deposit payment information, marital status and spouse details, prior marriages, and work-disability information for applicants or children, including onset timing and disabling conditions, with required next-step routing across sections.

LanguageEnglish

CategoryForms

FormatPDF

Pages20

Reading Time7 min

AccessFree to download

Part I--Basic Eligibility

Applicant and claimant identity

Addresses and direct deposit payment

Marital status and spouse details

Work disability and disabling conditions

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 Space DATE STAMP Filing Date (month, day, year) Receipt Protective FS-SSA/APP FS-REFERRED Preferred Language Written: Spoken: TYPE OF CLAIM Individual Individual with Ineligible Spouse Couple Child Child with Parents PART I--BASIC ELIGIBILITY--Answer the questions below beginning with the first moment of the filing date month. Form SSA-8000-BK (01-2012) Page 1 Destroy Prior Editions | 1. | (a) First Name, Middle Initial, Last Name | | Sex | | | | Birthdate
(month, day, year) | | | | Social Security Number | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | Male
Female | | | | | | | | | | | | | | (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: Mother's Father's | | | | | | | | | | | | | | | | | Maiden Name: Name: Go to \#2 | | | | | | | | | | | | | | | | 2. | Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route) | | | | | | | | | | | | | | | | | City and State
Philadelphia, PA | | | | | | | | | ZIP Code | | | | | County
Philadelphia | | 3. | Claimant's Residence Address (If different from applicant's mailing address) | | | | | | | | | | | | | | | | | City and State | | | | | | | | | ZIP Code | | | | | County | | 4. | DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION) | | | | | | | | | | | | | | | | | Routing Transit Number | Account Number | | | | | | | Checking
Savings | | | | | Enroll in Direct Express
Direct Deposit Refused | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 5. | (a) Are you married? | | | YES Go to (b) NO Go to \#6 | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | (b) Date of marriage: (month, day, year) | | | | | | | | | | (c) Spouse's Name (First, middle initial, last) | | Birthdate
(month, day, year) | | | | 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 : (month, day, year) | | | | | | | | | | (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 | | | YES
Go to (b) | | You
NO Go to \#7 | | Your Spouse, if filing
YES NO
Go to (b) Go to \#7 | | | (b) Give the following information about your former spouse. If there was more than one forme

FAQs

What is the SSI application used for?

It is used to apply for Supplemental Security Income (SSI) and any federally administered state supplementation under Title XVI, and where applicable, related medical assistance under Title XIX.

What information is required in Part I for basic eligibility?

Part I collects identity details, preferred language, claim type, filing date, addresses, direct deposit payment details, and answers about marital status and disability/work ability.

How does the form handle applicants who cannot work due to illnesses or conditions?

It asks for the date the applicant became unable to work and what illnesses, injuries, or conditions apply, then routes to additional questions about parent-related eligibility when the inability began before age 22.

Sep 19, 2026

Upload by Mason