TN 1 (10-89)

A. Introduction

Form SSA-8010-BK, Statement of Income and Resources, collects information about deemors which is not collected on other forms. It is not designed for self-help completion.

B. When to Use

1. When to Use SSA-8010-BK

Use form SSA-8010-BK, or selected portions of it, to collect information about the income and resources of these deemors:

• parent(s) or the parent and spouse of the parent

• essential person

• sponsor of an alien (and the sponsor's spouse living in the same household with the sponsor).

Interviewers may use the SSA-8010-BK to record an ineligible child's income, where material. Modify the form into a Statement of Income. See SI 01310.610 C.

Interviewers may also use the modified form to record a report of changes in income, especially when there are several types of income to record.

2. When Not to Use the SSA-80100BK

Interviewers should not use the SSA-8010-BK for eligible or ineligible spouse since the SSI application and other forms capture all the spouse's income and resources information.

3. Decide Which Form to Use

Use this chart to decide which form to use in each deeming situation.

1. Initial Claims

   IF APPLICANT IS...	THEN USE FORM...	REFERENCE
   An individual living with a spouse	SSA-8000-BK	SI 00604.001
   A child under age 18 living with a parent AND parent is not filing for SSI at the same time	SSA-8010-BK	SI 01320.500 SI 01330.200
   A child under age 18 living with a parent who is filing for SSI at the same time	SSA 8000-BK Place a photocopy of the parent's SSA-8000-BK in the child's claim folder.	SI 01320.620 SI 01320.630
   A previously eligible qualified individual who still has essential person (EP) in the household	SSA-8010-BK Exception : If the EP is an ineligible spouse, use form SSA-8000-BK. No SSA-8010-BK is required.	SI 00501.100 SI 01320.800
   An alien who has a sponsor	SSA-8010-BK Exception : If the sponsor is an ineligible spouse, use form SSA-8000-BK. No SSA-8010-BK is required.	SI 01320.910 SI 01320.920
   An alien who has multiple sponsors	SSA-8010-BK for each sponsor (unless the sponsors are married to each other).	SI 01320.950

   NOTE: This chart should not be used to determine whether deferral of nondisability development applies.

   • See SI 00603.010 to determine whether simultaneous development or deferred development applies.

   • See SI 00602.001 ff. if the claimant clearly does not meet a requirement for eligibility.

   • See SI 00603.035 and use this chart when processing a deferred claim after a medical allowance.

2. Posteligibility Situations

   IF THE RECIPIENT IS...	THEN USE FORM...	REFERENCE
   An eligible individual living with a spouse	SSA-8203-BK; or SSA-8202 and document changes in the income or resources of the ineligible on a signed statement.	SI 02305.032
   A child under age 18 living with a parent (or a parent and the spouse of a parent)	SSA-8010-BK	SI 01320.500 SI 01330.200
   A qualified individual with an EP	SSA-8010-BK Exception : If the EP is the recipient's spouse, no SSA-8010-BK is required.	SI 01320.800 SI 01330.400
   An alien who has a sponsor	SSA-8010-BK Exception : If the sponsor is the recipient's spouse, no SSA-8010-BK is required.	SI 01320.910 SI 01320.920 SI 01330.500

3. Ineligible Child(ren)

   IF THE INCOME OF AN INELIGIBLE CHILD IS MATERIAL IN A(N)...	THEN USE FORM...	REFERENCE
   Initial claim	SSA-8000-BK (Remarks section) or a signed statement (e.g., SSA-795) or a modified SSA-8010-BK	SI 01310.610
   Posteligibility	SSA-8203-BK (Remarks section) or a signed statement (e.g., SSA-795) or a modified SSA-8010-BK to record effective dates and reason for any change(s) in an ineligible child's income.	SI 01310.610