Transcription of APPLICATION FOR SUPPLEMENTAL SECURITY …
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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. DEFFERRED FS-SSA APP ABAP FS-REFERRED FILING DATE Month, Day, Year Actual or Protective TYPE OF CLAIM INDIVIDUAL WITH INELIGIBLE SPOUSE COUPLE INDIVIDUAL CHILD CHILD WITH PARENTS PART I BASIC ELIGIBILITY 1.
Form SSA-8001-F5 (12-2002) Page 2 PART II – LIVING ARRANGEMENTS TODAY – (Use “Remarks” to explain any change between the first moment of the filing date month and today.)
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