TN 1 (10-89)

A. Introduction

The interviewer must complete the SSA-8010-BK. Make sure any individual signing the form understands

• the purpose of the interview

• the uses of the information

• the penalties for giving false information.

Following are the general requirements for completing the SSA-8010-BK.

B. Procedure — General

1. Related Information

Record information obtained from the individual(s) signing the form.

Use other forms to record reports from other persons and sources, deeming computations, or verifying information from other sources. Do not add such information to a completed SSA-8010-BK.

2. Using the Form for a Couple

Enter responses by the individual making the statement under the column labeled You and information about the spouse under Your Spouse .

Do not use one SSA-8010-BK to combine income and resources information for people who do not have a marital relationship as defined in SI 00501.150C.

3. Changing Answers

Ask the individual to initial or sign any change in an answer. (See GN 00205.015 for the procedure if the individual cannot write.)

NOTE: Do not change answers once the individual has signed the SSA-8010-BK. Take a statement on another signed form (e.g., an SSA-795) explaining the change.

4. Dollar Amounts

Enter actual stated amounts in dollars and cents; do not round them.

5. Answer Unknown

Enter “unknown” and begin appropriate development when the individual does not know the answer to a question.

C. Procedure — Use as a Statement of Income

When you use the form as a Statement of Income (SI 01310.600 B.3.c.), modify the SSA-8010-BK as follows:

• Line through the phrase “AND RESOURCES” in the title (page 1)

• Cross out questions 6-12 relating to resources.