SSA-8202

Statement For Determining Eligibility For Supplemental Security Income Payment

Download and Print the SSA-8202

Request may not be processed if the form is incomplete or illegible.

If the name and address below are not correct, please cross out the part that is wrong and write in the correct information.

WHEN ANSWERING THESE QUESTIONS, REFER TO THIS DATE

1.SINCE THE DATE ABOVE , have you moved to a new address?
If ''YES,'' please give your new address: - Yes - No

ADDRESS (Number, Street, City, State, ZIP Code)
DATE YOU MOVED

2. SINCE THE DATE ABOVE , have you spent a full calendar month in a hospital, nursing home or any place other than where you live? (Also, include trips outside of the United States that lasted 30 days or more.)  Yes - No
If " YES ," please give the following information:

NAME(S) OF PLACE(S) WHERE YOU STAYED:
ADDRESS(ES) (Number, Street, City State, ZIP Code)

DATE(S) FIRST STAYED (month/day/year)

DATE(S) LEFT (month/day/year)

3. SINCE THE DATE ABOVE, has anyone moved into or out of the place where you live (also, report births and deaths of people living with you)?  Yes - No

And much more...