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Get SSA-8000-BK 2017

Form Approved OMB No. 0960-0229 Do Not Write in This Space DATE STAMP TEL SOCIAL SECURITY ADMINISTRATION 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. Send only comments relating to our time estimate to this address not the completed form. REPORTING RESPONSIBILITIES The amount of a Supplemental Security Income SSI check is based on the information told to us. You must tell Social Security every time there is a change-while we process your application AND if you start receiving SSI. Once authorized our permission to contact financial institutions remains in effect until one of the following occurs 1 you or your spouse notify us in writing that you are canceling your permission 2 your application for SSI is denied in a final decision 3 your eligibility for SSI terminates or 4 we no longer consider your spouse s income and resources to be available to you. If you or your spouse do not give or cancel your permission you may not be eligible for SSI and we may deny your claim or stop your payments. 63. I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. Claimant s Residence Address If different from applicant s mailing address DIRECT DEPOSIT PAYMENT ADDRESS FINANCIAL INSTITUTION Routing Transit Number Account Number Enroll in Direct Express Savings Form SSA-8000-BK 01-2012 Destroy Prior Editions Checking Direct Deposit Refused Page 1 5. If you or your spouse do not give or cancel your permission you may not be eligible for SSI and we may deny your claim or stop your payments. 63. I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information or causes someone else to do so commits a crime and may be sent to prison or may face other penalties or both. You may send comments on our time estimate above to SSA 6401 Security Blvd. Baltimore MD 21235-6401. Send only comments relating to our time estimate to this address not the completed form. REPORTING RESPONSIBILITIES The amount of a Supplemental Security Income SSI check is based on the information told to us. Enter the item number before each explanation. If you need more space use a signed form SSA-795. PART VIII -- IMPORTANT INFORMATION AND SIGNATURES 62. IMPORTANT INFORMATION--PLEASE READ CAREFULLY u Failure to report any change within 10 days after the end of the month in which the change occurs could result in a penalty deduction. u The Social Security Administration will check your statements and compare its records with records from other State and Federal agencies including the Internal Revenue Service to make sure you are paid the correct amount. u We have asked you for permission to obtain from any financial institution any financial record about you that is held by the institution. We will ask financial institutions for this information whenever we think it is needed to decide if you are eligible or if you continue to be eligible for SSI benefits.

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