SSI / SSDI Filing Worksheet

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① Client Info & Living Situation

↓

② Which benefit?

↓

③ SSA Forms → ④ ID → ⑤ Medical → ⑥ HMIS

↓

⑦a Financial (SSI)

⑦b Work History (SSDI)

↓

⑧ Daily Life → ⑨ Sign → ✓ Filed

① Client Info & Living Situation

Full legal name? Other names used?

Date of birth?

Social Security number?

Born in the US? (If no — immigration status?)

Where did you sleep last night?

How long have you been homeless?

Shelters? Which ones, and when?

Outreach teams or case managers?

Best way to reach you?

② Which Benefit? — Check One

SSI only — little/no income, no work history needed SSDI only — has work history, paid into Social Security Both — file for both, let SSA decide

Not sure? File for BOTH. Costs nothing extra.

③ SSA Forms (from ssa.gov)

SSA-8000-BK — SSI application (SSI/Both) SSA-16-BK — SSDI application (SSDI/Both) SSA-3368-BK — Disability Report — doctors, diagnoses, meds SSA-3369-BK — Work History — last 15 years (SSDI/Both) SSA-3373-BK — Function Report — daily life described SSA-827 — Medical Release — one signed copy per provider SSA-1696 — Representative — signed by you and client

④ Identity Documents

Photo ID Social Security card or verified SSN Birth certificate or proof of citizenship Immigration docs (if not a citizen)

Missing anything? Plan to get it?

⑤ Medical

Ask:

What health problems keep you from working?

When did each start?

What doctors? (Names, clinics, addresses, phones)

ER/hospital visits? Where, when?

Medications? (Name, dose, prescriber)

Surgeries, X-rays, MRIs, tests?

Mental health treatment? Who, where?

Drug/alcohol treatment? Where, when?

Records gathered:

Primary care records Specialist records Hospital / ER records Mental health records Substance use records Medication list Test results

⑥ HMIS Records (you pull)

Client profile printout Homeless verification Chronic homeless docs (if 12+ mo) Service history Case notes Assessment scores

⑦a Financial (SSI/Both)

Income now? From where, how much?

Benefits already? (SNAP, TANF, GA, veterans?)

Income proof or zero-income statement Bank statements or no-account statement Vehicle/property info

⑦b Work History (SSDI/Both)

Last job? (Employer, duties, dates)

Other jobs in last 15 years?

Physical duties of each?

Why leave each?

When did you stop being able to work? What happened?

W-2s Tax returns SSA earnings record Past employer contacts

⑧ Daily Life (Function Report)

Normal day, morning to night?

Dress, bathe, cook, clean without help?

How far can you walk?

How much lift/carry?

How long sit? Stand?

Trouble concentrating/remembering?

Trouble getting along with people?

⑨ Review & Sign

Anything about your health I missed?

Anyone else I should talk to?

Client understands what was filed Client agreed I can be contacted by SSA All forms signed/dated SSA-1696 signed by both Copies given to client

Client signature & date

Preparer signature & date

SSI / SSDI Filing Worksheet

✓ All fields complete!

① Client Info & Living Situation

② Which Benefit? — Check One

③ SSA Forms (from ssa.gov)

④ Identity Documents

⑤ Medical

Ask:

Records gathered:

⑥ HMIS Records (you pull)

⑦a Financial (SSI/Both)

⑦b Work History (SSDI/Both)

⑧ Daily Life (Function Report)

⑨ Review & Sign

✓ Filed