Application For Supplemental Security IncomeApplication For Supplemental Security IncomeApplication For Supplemental Security Income
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Form Approved
OMB No 0960-0229

TEL

SOCIAL SECURITY ADMINISTRATION

Do not write in this space

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.

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.

FS-SSA/APP

Filing Date
Month, Day, Year
Actual

TYPE OF CLAIM

Individual with
Ineligible Spouse

Couple

FS-REFERRED

Individual

or

Child

Protective

Child with Parent(s)

PART I–BASIC ELIGIBILITY– The questions in this section pertain to the period beginning with the first
moment of the filing date month through the date this application is signed
unless a question specifies a different time per