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Get Form Ssa 8001 Bk 2008

Sex 4. Social Security Number Date of Marriage month day year Other Name s and Social Security Number s you your spouse/parents used a Your Other Name s including Maiden Name Your Other Social Security Number s b Spouse s/Mother s Other Name s including Maiden Name Spouse s/Mother s Other Social Security Number s c Father s Other Name s FORM SSA-8001-BK 01/2008 Destroy Prior Editions Father s Other Social Security Number s Page 1 10. SOCIAL SECURITY ADMINISTRATION Form Approved OMB No* 0960-0444 Do Not Write in This Space TEL APPLICATION FOR SUPPLEMENTAL SECURITY INCOME 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. DEFERRED ABAP FS-SSA/APP FS-REFERRED Filing Date Month Day Year Receipt Protective Preferred Language TYPE OF CLAIM Individual Ineligible Spouse Couple Child Child with Parents PART I--BASIC ELIGIBILITY-- Answer the questions below beginning with the first moment of the filing date month. 1. First Name Middle Initial Last Name 2. Sex 3. Birthdate month day year Male Female 5. Spouse s/Parent s Name s 6. Your Place of Birth City and State or Foreign Country 11. Spouse s Place of Birth City and State or Foreign Country 12. If you are filing for yourself go to a if you are filing for a child go to e. You a Are you unable to work because of illnesses injuries or conditions YES Go to b Your Spouse if filing NO Go to 13 b Enter the date you became unable to work Go to c c What are your illnesses injuries or conditions Brief Description Go to d Provide name s and Number s in Remarks. d If you were unable to work because of illnesses parent who is age 62 or older unable to work because of illnesses injuries or conditions or deceased e When did the child become disabled Go to f f What are the child s disabling illnesses injuries or conditions Go to g g Does the child have a parent or stepparent who is 62 or older unable to work because of illnesses If you and your spouse filing for benefits were a United States citizen at birth go to 17 otherwise go to a. a Are you a naturalized United States citizen b Are you an American Indian born outside the United States c Check the block that shows your American Indian status. American Indian born in Canada Member of a Federally recognized Indian Tribe Name of Tribe Other American Indian Explain in Remarks then Go to d Page 2 13. d Check the block below that shows your current immigration status. Amerasian Immigrant Lawful Permanent Resident Refugee Date of entry month day year Asylee Date status granted month day year Conditional Entrant Parolee for One Year Cuban/Haitian Entrant Deportation/Removal Withheld Other e If you have status or have applied for status as the spouse child or parent of a child of a United States citizen or a lawfully admitted permanent resident Go to 15 otherwise Go to 17.

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