Form SSA-8000-BK - 6-2019 - Application for Supplemental Security Income (SSI)

Sep 19, 2026

Application form SSA-8000-BK (06-2019) for requesting Supplemental Security Income (SSI) and related federally administered state supplementation under Title XVI, and where applicable medical assistance under Title XIX. Collects applicant and claimant identity details, filing information, preferred language, claim type, basic eligibility answers, mailing and residence addresses, direct deposit payment details, and marital history including dates, spouse information, living arrangements, and related questions about inability to work and blindness.

LanguageEnglish

CategoryForms

FormatPDF

Pages24

Reading Time8 min

AccessFree to download

Part 1 - Basic Eligibility

Applicant identity and name history

Addresses and contact information

Direct deposit payment information

Marital status and spouse details

Additional eligibility questions

Form SSA-8000-BK (06-2019) UF Discontinue Prior Editions Social Security Administration Page 1 of 24 OMB No. 0960-0229 | 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. | | | Do Not Write in This Space
DATE STAMP | | | | 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. | | | | | | | | | | Filing Date (MM/DD/YYYY) | | | | | | | Receipt Protective | | | | | | | SNAP-SSA/APP | SNAP-Referred | | | | | | Preferred Language
Written: Spoken: | | | | TYPE OF CLAIM Individual | Individual with Ineligible Spouse | Couple Child | | | Child with Parents | PART 1-BASIC ELIGIBILITY-Answer the questions below beginning with the first moment of the filing date month. | 1. | (a) First Name, Middle Initial, Last Name | | | Sex Male
Female | | Birthdate
(MM/DD/YYYY) | | Social Security Number | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | (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: | | | | | | | | | | Parent 1's Name (s) | | Parent 2's Name (s) | | | | | | | | Parent 1's Other Name (s) (Including Name at Birth) | | Parent 2's Other Name (s) (Including Name at Birth)
Go to \#2 | | | | | | | 2. | Applicant's Mailing Address (Number & Street, Apt. No. , P.O. Box, Rural Route) | | | | | | | | | | City and State (U. S. )/State/Province/Region (Foreign) | | | | ZIP Code/Postal Code | | | County/Country | | 3. | Claimant's Residence Address (If different from applicant's mailing address) | | | | | | | | | | City and State (U. S. )/State/Province/Region (Foreign) | | | | ZIP Code/Postal Code | | | County/Country | | 4. | DIRECT DEPOSIT PAYMENT INFORMATION (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: (MM/DD/YYYY) | | | | | | | | | | (c) Spouse's Name (First, middle initial, last) | | | | Birthdate
(MM/DD/YYYY) | | | 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 : (MM/DD/YYYY) | | | | | | | | | | (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 | | You | | | | Your Spouse, if filing YES NO Go to (b) Go to 6(c) | | | | | | YES Go to (b) | | NO Go to 6(c) | |

FAQs

What is this form used for?

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

What information does the form request for basic eligibility?

It requests identity details (including name history and Social Security numbers), mailing and residence addresses, and direct deposit payment information, along with answers to eligibility questions.

How does the form handle marital status questions?

It asks whether you are married, the marriage date, spouse details, and whether you and your spouse live together. It also asks about prior marriages and, in some cases, about living arrangements and other individuals presenting as a married couple.

Sep 19, 2026

Upload by Lucas Martin