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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.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/application-for-supplemental-security-income-ssi-form-ssa-8000-bk-01-2012-complete-eligibility-questions/305586/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/application-for-supplemental-security-income-ssi-form-ssa-8000-bk-01-2012-complete-eligibility-questions/305586.png","ImageObject",442,249,{"name":88,"@type":89},"Mason","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-10","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the SSI application used for?","Question",{"text":109,"@type":110},"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.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information is required in Part I for basic eligibility?",{"text":114,"@type":110},"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.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the form handle applicants who cannot work due to illnesses or conditions?",{"text":118,"@type":110},"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.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},305586,1790887660,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":142},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI)  \nNote: Social Security Administration staff or others who help people apply for SSI will fill out this form for you.  \nI 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.  \nDo Not Write in This Space  \nDATE STAMP  \nFiling Date (month, day, year)  \nReceipt Protective  \nFS-SSA/APP FS-REFERRED  \nPreferred Language  \nWritten: Spoken:  \nTYPE OF CLAIM  \nIndividual  \nIndividual with Ineligible Spouse  \nCouple  \nChild  \nChild with Parents  \nPART I--BASIC ELIGIBILITY--Answer the questions below beginning with the first moment of  \nthe filing date month.  \nForm SSA-8000-BK (01-2012) Page 1  \nDestroy Prior Editions  \n\n| 1. | (a) First Name, Middle Initial, Last Name |  | Sex |  |  |  | Birthdate\u003Cbr>(month, day, year) |  |  |  | Social Security Number |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  | | Male\u003Cbr>Female |  |  |  |  |  |  |  |  |  |  |  |\n|  | (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) |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | (c) Other Name(s) |  |  |  |  | Other Social Security Number(s) used |  |  |  |  |  |  |  |  |  |\n|  | (d) If you are also filing for Social Security Benefits, go to \\#2; otherwise complete the following: Mother's Father's |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Maiden Name: Name: Go to \\#2 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 2. | Applicant's Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | City and State\u003Cbr>Philadelphia, PA |  |  |  |  |  |  |  |  | ZIP Code |  |  |  |  | County\u003Cbr>Philadelphia |\n| 3. | Claimant's Residence Address (If different from applicant's mailing address) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | City and State |  |  |  |  |  |  |  |  | ZIP Code |  |  |  |  | County |\n| 4. | DIRECT DEPOSIT PAYMENT ADDRESS (FINANCIAL INSTITUTION) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Routing Transit Number | Account Number |  |  | |  |  |  | Checking\u003Cbr>Savings |  |  |  |  | Enroll in Direct Express\u003Cbr>Direct Deposit Refused |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\n\n| 5. | (a) Are you married? |  |  |  YES Go to (b)  NO Go to \\#6 |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | (b) Date of marriage: (month, day, year) |  |  |  |  |  |  |  |\n|  | (c) Spouse's Name (First, middle initial, last) |  | Birthdate\u003Cbr>(month, day, year) |  |  |  | Social Security Number |  |\n|  | (d) Did your spouse ever use any other names (including maiden name) or Social Security Numbers? |  |  |  | YES Go to (e)  NO Go to (f) |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  | (e) Other Name(s) |  |  | Other Social Security Number(s) Used |  |  |  |  |\n|  | (f) Are you and your spouse living together? |  |  |  | YES Go to \\#6  NO Go to (g) |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |\n|  | (g) Date you began living apart : (month, day, year) |  |  |  |  |  |  |  |\n|  | (h) Address of spouse or name of someone who knows where spouse is. (Complete only if spouse is age 65, blind or disabled.) |  |  |  |  |  |  |  |\n| 6. | (a) Have you had any other marriages? If never married, check this box  |  |  |  YES\u003Cbr>Go to (b) |  | You\u003Cbr> NO Go to \\#7 |  | Your Spouse, if filing\u003Cbr> YES  NO\u003Cbr>Go to (b) Go to \\#7 |\n|  | (b) Give the following information about your former spouse. If there was more than one forme","cbCail91R3rQT75R","https://ap.wps.com/l/cbCail91R3rQT75R","pdf",603499,20,"English","# Part I--Basic Eligibility\n## Applicant and claimant identity\n## Addresses and direct deposit payment\n## Marital status and spouse details\n## Work disability and disabling conditions","[{\"question\":\"What is the SSI application used for?\",\"answer\":\"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.\"},{\"question\":\"What information is required in Part I for basic eligibility?\",\"answer\":\"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.\"},{\"question\":\"How does the form handle applicants who cannot work due to illnesses or conditions?\",\"answer\":\"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.\"}]","APPLICATION FOR SUPPLEMENTAL SECURITY INCOME (SSI) - Form SSA-8000-BK (01-2012) - Complete eligibility questions | PDF",1789826299,7]