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The document is the SSA-8000-BK form, used to apply for Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act. It includes sections for personal information, eligibility questions, living arrangements, resources, income details, and potential eligibility for other benefits like SNAP and Medicaid. The form requires detailed information about the applicant's financial situation, marital status, and any prior claims or benefits received. It emphasizes the importance of reporting changes in circumstances that may affect SSI eligibility.

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