Take Questionnaire

The questions on this page will help us start to determine if you may be eligible for any benefits. After you complete this page, you may see other pages asking for more information. You must answer all questions.

If you do not take any action within the screening tool for an extended period of time, the information you have entered will be deleted from the system and must be reentered.
1. What is your date of birth? (Enter date in mm/dd/yyyy format.) Additional Information

Enter your date of birth as a 2-digit month, a 2-digit day and a 4-digit year. For example, if you were born on July 5, 1935 enter 07/05/1935.


    
2. Where do you live? Additional Information

Only people who live in the U.S. or the Northern Mariana Islands can receive SSI. People who are not U.S. citizens may not be able to receive Social Security benefits unless they live in the U.S., the Northern Mariana Islands, Puerto Rico, Guam, American Samoa or the U.S. Virgin Islands. Choose the option that describes where you live. If you live somewhere other than the places listed, choose "Other".


One of the 50 states or the District of Columbia
Puerto Rico, Guam, American Samoa, the Northern Mariana Islands or the U.S. Virgin Islands
Other 		   
3. In which U.S. State do you live? Additional Information

Choose the state where you live from the drop-down list.


    
4. Choose the option that best describes your citizenship status: Additional Information

Some benefits are only available to U.S. citizens or certain non-citizens who have been lawfully admitted to the U.S.

Choose the option that describes your U.S. citizenship or non-citizen status.


U.S. Citizen
U.S. National
Non-Citizen legally admitted to the U.S
American Indian
Other 		   
5. Are you currently married? Additional Information

If you are married, you may be entitled for benefits based on your spouse's work. On the other hand, if you are eligible for Social Security retirement or disability benefits, your spouse also may be eligible. Your marital status also will help us determine if you could get certain Social Security survivor's benefits.

If you are currently married, choose the "Yes" option; otherwise, choose the "No" option.


Yes
No 		   
6. Choose the option that best describes where you live: Additional Information

Your response to this question will help us determine if you could get SSI. People who are in a jail or correctional facility cannot get SSI. People who live in a nursing home where Medicaid pays the cost could get SSI if their income is less than $30 per month.

Choose the option that best describes where you live.


Private residence
Nursing home (cost paid by Medicaid)
Jail or correctional facility
Other facility
Other 		   
7. Choose the option that best describes your current student status: Additional Information

Your answer to this question will help us determine if you could get Social Security benefits as a child. Choose the option that describes your current student status.


Not a student
Grade K through 12
College/university/graduate school
Technical or vocational school 		   
8. How much do you earn each month from working? Example: $2500 Additional Information

Your answer to this question will help us determine if you could get SSI or have your Medicare premiums paid by your State. Enter the average amount (dollars only) you earn each month from working before any deductions are taken out. Do not enter the dollar sign or commas. For example, if you earn $756.23 each month, enter 756.


    
9. Are you receiving any of the following? (Check all that apply.) Additional Information

Check the box next to each of the benefits that you already receive. Check more than one box if you receive more than one of the benefits listed. If you do not receive any of the benefits listed, check the last box.


Social Security retirement benefits
Social Security disability benefits
Supplemental Security Income (SSI) benefits
Social Security child?s benefits
Railroad retirement or disability benefits
Medicare
Social Security spouse?s or divorced spouse?s benefits
Social Security widow or widower?s benefits
Social Security parent?s benefits
I do not receive any of these benefits 		   
10. How many times have you been married? (0-10) Additional Information

If you have ever been married, you may be entitled to benefits based on your spouse?s or former spouse's work. Your marital status also will help us determine if you could get certain Social Security survivor's benefits. Enter a number (from 0 to 10) to show how many times you have been married.

If you have never been married, enter 0.