APPLICATION FOR SUPPLEMENTAL SECURITY …

FORM APPROVED SOCIAL SECURITY ADMINISTRATION TEL OMB NO. 0960-0444 Form SSA-8001-F5 (12-2002) Page 1 APPLICATION FOR SUPPLEMENTAL SECURITY INCOME Do not write in this space. 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.

Form SSA-8001-F5 (12-2002) Page 4 REMARKS (CONTINUED) IMPORTANT INFORMATION – PLEASE READ CAREFULLY The Social Security Administration will check your statements and compare its records with records from other State and

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  Applications, Security, Your, Supplemental, Application for supplemental security

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