SOCIAL SECURITY ADMINISTRATION
FORM APPROVED OMB No. 0960-0416 For Official Use Only EI SSN Spouse's Name Spouse's SSN Check the Ones That Apply NC C M FS-APP Interviewer's Initials N FS-REF Date Received DO Code
STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR SUPPLEMENTAL SECURITY INCOME PAYMENTS
Name and Address
WHEN ANSWERING THE QUESTIONS, REFER TO THIS DATE
MARITAL STATUS/TRAVEL OUTSIDE THE...
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