Form SSA-8000-BK, Application for Supplemental Security Income (SSI) Completed Form Examples and Samples

Client Intake Session - January 15, 2026

**Client Name:** Sarah Jane Miller
**DOB:** August 22, 1975
**SSN:** 987-65-4321
**Contact:** (555) 123-4567

Sarah Miller, a 50-year-old female, came in today to discuss applying for Supplemental Security Income (SSI). She confirmed she is a U.S. citizen by birth, born in Chicago, Illinois. She states she has never used any other names or Social Security Numbers. Her preferred language for all communications, both written and spoken, is English. She reports that she has been unable to work due to a debilitating chronic illness since March 10, 2025. She clarified that her condition does not involve blindness or low vision. She is applying as an individual.

Her current residence is an apartment located at 456 Oak Avenue, Apt 3B, Springfield, IL 62704, in Sangamon County. This also serves as her mailing address. She has lived there alone since June 1, 2023. She is the sole renter and responsible for the $950 monthly rent payment. No one else lives with her or contributes to her household expenses, and she doesn't have any loan agreements for her share of expenses. She mentioned that no one outside her household provides her with shelter items or money for them.

Financially, Ms. Miller's resources are very limited. She confirmed she does not own any trusts, vehicles, land, or other significant property. Her only asset is a checking account at First National Bank, located at 100 Main St, Springfield, IL 62701, with an approximate balance of $150. The account number is 9876543210 and the routing number is 123456789. She would like her SSI payments directly deposited into this account. She does not have any savings accounts, stocks, bonds, or life insurance policies. She has not acquired or disposed of any significant assets recently and does not anticipate any changes in her resources. She provided consent for SSA to obtain her financial records.

Regarding income, Sarah currently receives $250 per month in Supplemental Nutrition Assistance Program (SNAP) benefits from the Illinois Department of Human Services, which she expects to continue. She has no wages, self-employment income, or other income sources, nor does she expect any in the next 14 months. She has no history of overpayments from other benefits. She also confirmed she has no unsatisfied felony warrants and has not received any substantial non-cash gifts. While she has a work history under the U.S. Social Security System, she has no military service, railroad, federal, state, or union pension plans. She is not married and has never been married. She is also not currently a student.

She agreed to assign her rights to medical payments to the State Medicaid agency and stated she does not have any private health insurance or outstanding medical bills from the last three months.