Application for Supplemental Security Income MSSICS

SSS-SS-SSSS TRANSFER TO: XXXX

NAME: PPPPPPPPPPPPPPP PPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPP PPPP

[3-M] [4-M]

SEX (M/F): P BIRTHDATE (MMDDCCYY): PPPPPPPP

[5-M] [6-C]

BIRTHDATE PROOF: P PROOF TYPE: P

A=ALLEGED OR N/A P=PRE-AGE FIVE STATE/LOCAL PUBLIC

B=PRIMARY EVIDENCE BIRTH CERTIFICATE

C=CONVINCING EVIDENCE H=HOSPITAL BIRTH RECORD

F=DOB PREVIOUSLY ESTABLISHED N=NOTIFICATION OF BIRTH REGISTRATION

Q=DOB ESTABLISHED (OTHER) O=OTHER EVIDENCE OF AGE

[7-M] [8-C] [9-C]

BIRTHPLACE CITY: PPPPPPPPPPPPPPP STATE: PP OR COUNTRY: PP

[10-M]

OTHER NAMES USED OR SSNS PREVIOUSLY ISSUED/USED (Y/N): P

[11-M]

FILING, CLAIM PENDING, OR EVER ELIGIBLE FOR SSI SINCE 99/99/9999 (Y/N): P

MOTHER'S MAIDEN NAME: PPPPPPPPPPPPPPP PPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPP PPPP

[13-O]

FATHER'S NAME: PPPPPPPPPPPPPPP PPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPP PPPP

[14-O] [15-O]

DATE OF DEATH (MMDDCCYY): PPPPPPPP REMOVE DEATH (Y): X

[16-O]

REMOVE DEATH SUSPENSE (Y): X

PROOF (Y/N): X

[18-O]

SOURCE OF NOTIFICATION: P 1=FO 2=EDR 3=MBR 4=TREASUR

[19-O]

REMARKS (Y): X

ACLM - SSI CLAIMS APPLICATION

MSSICS SSI CLAIMS APPLICATION ACLM

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

APPLICATION TYPE: P 1=DEFERRED 2=FULL 3=ABBREVIATED

IF ABBREVIATED, TYPE: 9 1=EXCESS COUNTABLE INCOME

2=INELIGIBLE RESIDENT OF A PUBLIC INSTITUTION

3=ABSENCE FROM U.S.

4=EXCESS RESOURCES

5=NOT A CITIZEN or LAWFULLY ADMITTED ALIEN

6=NOT AGED 65, BLIND, OR DISABLED

7=FAILURE TO PURSUE CLAIM

8=INMATE OF A PENAL INSTITUTION

9=NOT A RESIDENT OF THE UNITED STATES

[4-O]

PROTECTIVE FILING DATE (MMDDYY): PPPPPP

EFFECTIVE FILING DATE (MMDDYY): 999999

PENDING FILE BEGIN DATE (MMYY): SSSS

[7-M]

TYPE OF APPLICANT: P 1=CLAIMANT 2=OTHER INDIVIDUAL 3=AGENCY

[8-O]

REMARKS (Y): X

ACLD - ADDITIONAL CLIENT DATA.

MSSICS ADDITIONAL CLIENT DATA ACLD

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

[2-D]

SS/SS/SSSS

MARRIED AS OF OR ANYTIME SINCE SS/SS/SSSS (Y/N): X

TERMINATED MARRIAGE(S) PRIOR TO SS/SS/SSSS (Y/N): X

POSSIBLE HOLDING OUT RELATIONSHIP AS OF OR ANYTIME SINCE SS/SS/SSSS (Y/N): X

[6-C] [7-C]

DISABLED (Y/N/U): X BLIND (Y/N/U): X

[8-C]

WHY NOT FILING FOR SSI: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[9-C]

NUMBER OF CHILDREN LIVING WITH CLAIMANT SINCE SS/SS/SSSS: PP

SSNS FOR APPLICABLE INELIGIBLE CHILDREN:

BBBBBBBBB BBBBBBBBB BBBBBBBBB BBBBBBBBB BBBBBBBBB

[11-d] [12-c]

SPONSOR OF ALIEN WITH PERMANENT LEGAL RESIDENT STATUS SINCE SS/SS/SSSS

WHO IS RECEIVING SSI (Y/N): X

[13-C]

SPONSOR HAS DEPENDENTS (Y/N): B

[14-O]

REMARKS (Y): X

ADIB - DISABILITY DATA

MSSICS DISABILITY DATA ADIB

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

[2-M] [3-M]

ONSET DATE (MMDDYYCC): VVVVVVVV DISABLED PRIOR TO AGE 22 (y/n): V

[4-M]

DISABLING CONDITION: VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

DISABILITY DECISION: V

1=CASE REFERRED FOR DETERMINATION [6-C]

2=PRESUMPTIVE DISABILITY PRESUMPTIVE ONSET DATE (MMDDYY): VVVVVV

3=TITLE II ADOPTION

4=ESCALATED TO RECONSIDERATION [7-C]

5=ESCALATED TO HEARING STATUTORILY BLIND (Y/N): X

6=NONE REQUIRED

7=CONVERSION CASE

MEDICAL FILE TO STATE AGENCY

[8-C] [9-C]

DESTINATION: XXX DATE (MMDDYY): 999999

TERMINAL CASE INDICATOR (Y/N): X

REMARKS (Y): X

ACIT – CITIZENSHIP (Deferred Application only)

MSSICS CITIZENSHIP ACIT

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

[2-C]

U.S. CITIZENSHIP STATUS: P

1=BIRTH IN THE U.S.

2=U.S. CITIZEN BORN OUTSIDE U.S.

3=NATURALIZED CITIZEN

4=ALIEN

5=NORTH AMERICAN INDIAN ALIEN EXCEPTION

DATE OF CHANGE (MMDDYY): 999999

IF U.S. CITIZENSHIP STATUS IS 1, 2, 3 OR 5, PROOF: 9

1=ALLEGATION

2=NUMIDENT (MEETS CRITERIA FOR Q CITIZENSHIP STATUS CODE)

3=NUMIDENT (NO U.S. PLACE OF BIRTH SHOWN)

4=BIRTH/BAPTISMAL RECORD

5=OTHER TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[6-C] [7-O]

CITIZENSHIP CHANGE (Y): X PRE-1/1/79 RECORD (Y/N): X

[8-O]

REMARKS (Y): X

NMDT - NUMIDENT ALERT (Deferred Application only)
**DISPLAY ONLY**

MSSICS NUMIDENT ALERT NMDT

[1]

SSN SSS-SS-SSSS

[2]

NAME SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS

[3]

PERSON TYPE SSSSSSSSSSSSSSSSS

[4]

BIRTHDATE SS/SS/SSSS

[5]

OTHER NAME SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS

[6]

NUMIDENT NAME SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS

[7]

NUMIDENT BIRTHDATE SS/SS/SSSS

[8]

NUMIDENT PLACE OF BIRTH SSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

[9]

NUMIDENT MOTHER'S NAME SSSSSSSSSS S SSSSSSSSSSSS

[10]

NUMIDENT FATHER'S NAME SSSSSSSSSS S SSSSSSSSSSSS

[11]

NUMIDENT DATE OF DEATH SS/SS/SSSS

[12]

NUMIDENT MULTIPLE SSN SSSSSSSSS SSSSSSSSS SSSSSSSSS

SSSSSSSSS SSSSSSSSS

[13]

REASON FOR NUMIDENT ALERT SSSSSSSSSSSSSSSSSSSSSSSSSSSS

ARES - RESIDENCY/PRESENCE IN U.S. (Deferred Application only)

MSSICS RESIDENCY/PRESENCE IN U.S. ARES

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

RESIDENT OF THE U.S. (Y/N): X

IF YES, FIRST U.S. RESIDENCY DATE (MMDDCCYY): PPPPPPPP

EVER RESIDED OUTSIDE THE U.S. SINCE FIRST U.S. RESIDENCY (Y/N): X

[5-C] [6-C]

IF YES, FROM (MMDDCCYY): TO (MMDDCCYY):

99999999 99999999

[8-C] [7-D]

CONTINUOUS PRESENCE IN U.S. SINCE SS/SS/SSSS (Y/N): X

[9-C] [10-C]

IF NO, LEFT (MMDDCCYY): RETURNED (MMDDCCYY):

99999999 99999999

REMARKS (Y): X

ADDR - MAILING/PAYMENT ADDRESS

MSSICS MAILING/PAYMENT ADDRESS PAGE 1 OF ADDR

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

ADDR: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[3-M] [4-C] [5-C]

CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP

[6-C] [7-C]

FOREIGN COUNTRY: PPPPPPPPPPPPPPPPPPPPPP POSTAL ZONE: PPPPPPPPPPPPPPP

[8-C] [9-M]

CONSULAR CODE: PPP STATE/COUNTY CODE: 99999X

[10-O] [11-O]

DOMESTIC PHONE NO: PPP PPP PPPP FOREIGN PHONE NO: PPPPPPPPPPPPPPP

PHONE INFO: XXXXXXXXXX

[13-O]

EXPLAIN C/O ADDRESS: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[14-M]

SELECT DIRECT DEPOSIT CHOICE: 9

1=BANK NO: PPPPPPPPP ACCT TYPE (C/S): P ACCT NO: PPPPPPPPPPPPPPPPP

2=ENROLL IN DIRECT EXPRESS 3=NO DIRECT DEPOSIT

[15-D]

NOTICE OPTION: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

[16-M]

ADD OR UPDATE NOTICE OPTION DUE TO VISUAL IMPAIRMENT (Y/N): X

REMARKS

AFIP – FINANCIAL INSTITUTIONS PERMISSION (Deferred Application only)

MSSICS FINANCIAL INSTITUTIONS PERMISSION AFIP

[1-o]

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

PERMISSION TO CONTACT FINANCIAL INSTITUTIONS (Y/N): X

IF NO, GOOD CAUSE ESTABLISHED (Y/N): X

[4-M]

PERMISSION AND / OR GOOD CAUSE CHANGED, DATE (MMDDYY): 999999

ineligibility notice date (mmddyy): 999999

[6-o] [7-C]

permission status change (y): x REMARKS (Y): X

CLLG - CLIENT LANGUAGE (SCREEN# 1)

TRANSFER TO: XXXX CLIENT LANGUAGE YRF1 CLLG

SS SSSSSSSSS SSSSS SSSSSSSSSS [1-M]

ENTER LANGUAGE CLIENT PREFERS FOR SPOKEN COMMUNICATION: PP

FOR WRITTEN COMMUNICATION: PP

1. ENGLISh 16. ARABIC 31.CHINESE-TOISHANESE

2. SPANISH 17. ARMENIAN 32. CHINESE-OTHER

3. AMERICAN SIGN LANGUAGE 18. ASSYRIAN 33. CREOLE-CRIOLLO

4. ALASKA NATIVE 19. BENGALI 34. CREOLE-FRENCH

5. ALBANIAN 20. BOSNIAN 35. CREOLE-HAITIAN

6. AMERICAN INDIAN-APACHE 21. BULGARIAN 36. CREOLE-OTHER

7. AMERICAN INDIAN-CHOCTAW 22. BURMESE 37. CROATIAN

8. AMERICAN INDIAN-CROW 23. CAMBODIAN 38. CZECH

9. AMERICAN INDIAN-DAKOTA 24. CHAMORRO 39. DUTCH

10. AMERICAN INDIAN-LAKOTa 25. CHINESE-CANTONESE 40. FARSI

11. AMERICAN INDIAN-NAKOTA 26. CHINESE-FORMOSAN 41. FINNISH

12. AMERICAN INDIAN-NAVAJO 27. CHINESE-MANDARIN 42. FRENCH

13. AMERICAN INDIAN-ZUNI 28. CHINESE-MIEN 43. GERMAN

14. AMERICAN INDIAN-OTHER 29. CHINESE-SHANGHAINESE 44. GREEK

15. AMHARIC 30. CHINESE-TAIWANESE 45. GUJARATHI (ENGLISH AND SPANISH ARE THE ONLY LANGUAGES IN WHICH NOTICES ARE CURRENTLY

ISSUED - OTHER WRITTEN LANGUAGE PREFERENCES ARE INFORMATIONAL ONLY)

s of s

CLLG - CLIENT LANGUAGE SCREEN# 2

TRANSFER TO: XXXX CLIENT LANGUAGE YRF1 CLLG

SS SSSSSSSSS SSSSS SSSSSSSSSS

[1-M]

ENTER LANGUAGE CLIENT PREFERS FOR SPOKEN COMMUNICATION: PP [2-M]

FOR WRITTEN COMMUNICATION: PP

46. HEBREW 61. MONGOLIAN 76. SOMALI

47. HINDI 62. NORWEGIAN 77. SWAHILI

48. HMONG 63. OROMO 78. SWEDISH

49. HUNGARIAN 64. PASHTO 79. SYRIAC

50. ILOCANO 65. PENNSYLVANIA DUTCH 80. TAGALOG

51. INDONESIAN 66. PERSIAN 81. THAI

52. ITALIAN 67. PIDGIN-HAWAIIAN 82. TONGAN

53. JAPANESE 68. POLISH 83. TURKISH

54. KHMER 69. PORTUGUESE 84. TWI (FANTI)

55. KOREAN 70. PUNJABI 85. UKRAINIAN

56. KURDISH 71. ROMANIAN 86. URDU

57. LAO (LAOTIAN) 72. RUSSIAN 87. VIETNAMESE

58. LITHUANIAN 73. SAMOAN 88. YIDDISH

59. MACEDONIAN 74. SERBO-CROATIAN 89. YUGOSLAVIAN

60. MALAYALAM 75. SLOVAK 90. OTHER

(ENGLISH AND SPANISH ARE THE ONLY LANGUAGES IN WHICH NOTICES ARE CURRENTLY

ISSUED - OTHER WRITTEN LANGUAGE PREFERENCES ARE INFORMATIONAL ONLY)

s of s

ALEF - LAW ENFORCEMENT

MSSICS LAW ENFORCEMENT ALEF

SSS-SS-SSSS TRANSFER TO: XXXX

ACCUSED OR CONVICTED OF A FELONY OR AN ATTEMPT TO COMMIT A FELONY (Y/N): X

[3-C] [4-C]

IF YES, IN WHICH STATE: XX OR COUNTRY: XXXXXXXXXXXXXXXXXXXXXX

[5-D] [6-C]

SINCE SS/SS/SSSS, FELONY OR ARREST WARRANT (Y/N): X

[7-M]

ON PAROLE OR PROBATION UNDER FEDERAL OR STATE LAW (Y/N): X

[8-C]

IF STATE LAW, WHICH STATE: XX

[9-D] [10-C]

SINCE SS/SS/SSSS, FEDERAL OR STATE ARREST WARRANT FOR PAROLE OR

PROBATION VIOLATION(Y/N): X

REMARKS (Y): X

AMAR - MARRIAGE DATA (page 1)

MSSICS MARRIAGE DATA PAGE 1 OF AMAR

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

SPOUSE NAME: VVVVVVVVVVVVVVV VVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVV VVVV

SPOUSE SSN: VVVVVVVVV

LIVING TOGETHER SINCE SS/SS/SSSS (Y/N): X

MARRIAGE DATE (MMDDCCYY): PPPPPPPP

[6-M]

MARRIAGE ENDED (Y/N): B

[7-C]

IF YES, DATE ENDED (MMDDCCYY): 99999999

[8-C]

REASON MARRIAGE ENDED: X 1=DIVORCE 2=DEATH 3=ANNULMENT 4=OTHER

[9-C]

IF OTHER, EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[10-O] [11-O] [12-O]

ANOTHER MARRIAGE (Y): X DELETE THIS SOURCE (Y): X REMARKS (Y): X

D. FACSIMILE 2: AMAR - MARRIAGE DATA

AMAR - MARRIAGE DATA (page 2)

MSSICS MARRIAGE DATA PAGE 2 OF AMAR

[1-0]

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

SPOUSE NAME: VVVVVVVVVVVVVVV VVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVV VVVV

[13-C]

SPOUSE BIRTHDATE (MMDDCCYY): 99999999

[14-C]

IF UNKNOWN, AGE: 999

[15-M]

IS SPOUSE DECEASED (Y/N): X

[16-C] [17-C]

IF NO, SPOUSE BLIND (Y/N/U): X SPOUSE DISABLED (Y/N/U): X

[18-C]

IF SEPARATED/FORMER SPOUSE IS AGED, BLIND, OR DISABLED,

ADDRESS:

XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX

[19-C]

DO YOU WANT TO FILE FOR SPOUSE (Y/N): X

[10-O] [12-O]

ANOTHER MARRIAGE (Y): X REMARKS (Y): X

LRES - RESIDENCE ADDRESS (#1)

MSSICS RESIDENCE ADDRESS PAGE 1 OF LRES

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[4-M] [5-O] [6-C]

CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP

[7-O] [8-O]

COUNTY: XXXXXXXXXXXXXXXXXX COUNTRY: PPPPPPPPPPPPPPPPPPPPPP

[9-O] [10-O]

CONSULAR CODE: PPP POSTAL ZONE: PPPPPPPPPPPPPPP

[11-M]

JURISDICTIONAL RESIDENCE ADDRESS SAME AS ABOVE (Y/N): X

[12-C]

CHILD OF ARMED FORCES MEMBER STATIONED

OUTSIDE THE U.S. BY ORDER (Y/N): X

[13-C]

IF YES, VERIFIED (Y/N): X

[14-C]

OUTSIDE U.S. RESIDENCE START DATE (MMYY): 9999

[15-M]

RESIDENCE STATE/COUNTY CODE: PPPPPP

[16-O]

STATE/COUNTY OVERRIDE (Y):

REMARKS (Y): X

LRES - RESIDENCE ADDRESS (#2)

MSSICS RESIDENCE ADDRESS PAGE 2 OF LRES

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[18-M]

RESIDENCE TYPE (SELECT ONE): 9 1 = HOUSE/APARTMENT/MOBILE HOME/

HOUSEBOAT

2 = ROOM (PRIVATE HOME)/FLAT FEE

3 = ROOM (COMMERCIAL ESTABLISHMENT)

4 = NON INSTITUTIONAL CARE

6 = INSTITUTION

[19-M]

RESIDENCE START DATE (MMDDYY): 999999

REMARKS (Y): X

RMEN - RESOURCES MENU

MSSICS RESOURCES MENU PAGE 1 OF RMEN

SSSSSSSSS SSSSS SSSSSSSSS

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO

THEIR NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES

LISTED BELOW:

01=SSSSSS SSSSS SSSS SSSS 04=SSSSSS SSSSS SSSS SSSS 07=SSSSSS SSSSS SSSS SSSS

02=SSSSSS SSSSS SSSS SSSS 05=SSSSSS SSSSS SSSS SSSS 08=SSSSSS SSSSS SSSS SSSS

03=SSSSSS SSSSS SSSS SSSS 06=SSSSSS SSSSS SSSS SSSS 09=SSSSSS SSSSS SSSS SSSS

(Y/N)

X VEHICLES (AUTO, TRUCK, CAMPER, BOAT, MOTORCYCLE, ETC.)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X LIFE INSURANCE

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X ITEMS HELD FOR POTENTIAL VALUE / INVESTMENT

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X CASH

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X FINANCIAL INSTITUTION ACCOUNTS (CHECKING, SAVINGS, CREDIT UNION,

CHRISTMAS CLUB, TIME DEPOSITS, INDIVIDUAL INDIAN MONEY ACCOUNT)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO

THEIR NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES

LISTED BELOW:

01=SSSSSS SSSSS SSSS SSSS 04=SSSSSS SSSSS SSSS SSSS 07=SSSSSS SSSSS SSSS SSSS

02=SSSSSS SSSSS SSSS SSSS 05=SSSSSS SSSSS SSSS SSSS 08=SSSSSS SSSSS SSSS SSSS

03=SSSSSS SSSSS SSSS SSSS 06=SSSSSS SSSSS SSSS SSSS 09=SSSSSS SSSSS SSSS SSSS

(Y/N)

X STOCKS AND BONDS (STOCKS, MUTUAL FUNDS, BONDS, U.S. SAVINGS BONDS)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X REAL PROPERTY/BUSINESS PROPERTY OR EQUIPMENT, OTHER THAN HOME,

(LAND, HOUSES, BUILDINGS, PROPERTY IN FOREIGN COUNTRIES)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X OTHER RESOURCES (LIFE ESTATES, UNPROBATED ESTATES, PENSION FUNDS,

TRUSTS, MINERAL RIGHTS, BELONGINGS HELD IN SAFETY DEPOSIT BOXES

OR OTHER ITEMS THAT CAN BE TURNED INTO CASH, ETC.)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO THEIR

NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES LISTED BELOW:

01=SSSSSS SSSSS SSSS SSSS 04=SSSSSS SSSSS SSSS SSSS 07=SSSSSS SSSSS SSSS SSSS

02=SSSSSS SSSSS SSSS SSSS 05=SSSSSS SSSSS SSSS SSSS 08=SSSSSS SSSSS SSSS SSSS

03=SSSSSS SSSSS SSSS SSSS 06=SSSSSS SSSSS SSSS SSSS 09=SSSSSS SSSSS SSSS SSSS

(Y/N)

X BURIAL CONTRACTS OR TRUST (FUNDS SET ASIDE FOR BURIAL)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

X BURIAL SPACES AND RELATED ITEMS (CEMETERY LOTS, CRYPTS, CASKETS, URNS,

OR OTHER REPOSITORIES FOR BURIAL OR ANY HEADSTONE OR MARKER)

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

[6-D] [7-D] [8-D]

X SINCE SS/01/SSSS, HAS SSSSS SSSSSS SSSS OR SSSSS SSSSSS SSSS

SOLD, TRANSFERRED TITLE, DISPOSED OF OR GIVEN AWAY ANY MONEY OR

OTHER PROPERTY, INCLUDING PROPERTY OR MONEY IN FOREIGN COUNTRIES?

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

[9-O]

X DISPLAY RESOURCES SUMMARY

01 X 02 X 03 X 04 X 05 X 06 X 07 X 08 X 09 X

G. FACSIMILE 4: RMEN - RESOURCES MENU

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO THEIR

NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES LISTED BELOW:

[2-D] [3-D] [4-D]

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

(Y/N)

B VEHICLES (AUTO, TRUCK, CAMPER, BOAT, MOTORCYCLE, ETC.)

10 B 11 B 12 B

B LIFE INSURANCE

10 B 11 B 12 B

B ITEMS HELD FOR POTENTIAL VALUE / INVESTMENT

10 B 11 B 12 B

B CASH

10 B 11 B 12 B

B FINANCIAL INSTITUTION ACCOUNTS (CHECKING, SAVINGS, CREDIT UNION,

CHRISTMAS CLUB, TIME DEPOSITS, INDIVIDUAL INDIAN MONEY ACCOUNT)

10 B 11 B 12 B

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO THEIR

NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES LISTED BELOW:

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

(Y/N)

B STOCKS AND BONDS (STOCKS, MUTUAL FUNDS, BONDS, U.S. SAVINGS BONDS)

10 B 11 B 12 B

B PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS

10 B 11 B 12 B

B REAL PROPERTY/BUSINESS PROPERTY OR EQUIPMENT, OTHER THAN HOME,

(LAND, HOUSES, BUILDINGS, PROPERTY IN FOREIGN COUNTRIES)

10 B 11 B 12 B

B OTHER RESOURCES (LIFE ESTATES, UNPROBATED ESTATES, PENSION FUNDS,

TRUSTS, MINERAL RIGHTS, BELONGINGS HELD IN SAFETY DEPOSIT BOXES

OR OTHER ITEMS THAT CAN BE TURNED INTO CASH, ETC.)

10 B 11 B 12 B

SINCE THE FIRST MOMENT OF SS/01/SSSS DO THE FOLLOWING PEOPLE OWN OR DO THEIR

NAMES APPEAR, EITHER ALONE OR WITH OTHER PEOPLE, ON THE RESOURCES LISTED BELOW:

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

(Y/N)

B BURIAL CONTRACTS OR TRUSTS (FUNDS SET ASIDE FOR BURIAL)

10 B 11 B 12 B

B BURIAL SPACES AND RELATED ITEMS (CEMETERY LOTS, CRYPTS, CASKETS, URNS,

OR OTHER REPOSITORIES FOR BURIAL OR ANY HEADSTONE OR MARKER)

10 B 11 B 12 B

[6-D] [7-D] [8-D]

X SINCE SS/01/SSSS, HAS SSSSS SSSSSS SSSS OR SSSSS SSSSSS SSSS

SOLD, TRANSFERRED TITLE, DISPOSED OF OR GIVEN AWAY ANY MONEY OR

OTHER PROPERTY, INCLUDING PROPERTY OR MONEY IN FOREIGN COUNTRIES?

10 X 11 X 12 X

[9-O]

X DISPLAY RESOURCES SUMMARY

10 X 11 X 12 X

SINCE THE FIRST MOMENT OF SS/01/SSSS DO YOU OWN OR DOES YOUR NAME APPEAR,

EITHER ALONE OR WITH OTHER PEOPLE, ON ANY OF THE FOLLOWING:

(Y/N)

X VEHICLES (AUTO, TRUCK, CAMPER, BOAT, MOTORCYCLE, ETC.)

X LIFE INSURANCE

X ITEMS HELD FOR POTENTIAL VALUE / INVESTMENT

X CASH

X FINANCIAL INSTITUTION ACCOUNTS (CHECKING, SAVINGS, CREDIT UNION,

CHRISTMAS CLUB, TIME DEPOSITS, INDIVIDUAL INDIAN MONEY ACCOUNT)

X STOCKS AND BONDS (STOCKS, MUTUAL FUNDS, BONDS, U.S. SAVINGS BONDS)

X PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS

X REAL PROPERTY/BUSINESS PROPERTY OR EQUIPMENT, OTHER THAN HOME,

(LAND, HOUSES, BUILDINGS, PROPERTY IN FOREIGN COUNTRIES)

SINCE THE FIRST MOMENT OF SS/01/SSSS DO YOU OWN OR DOES YOUR NAME APPEAR,

EITHER ALONE OR WITH OTHER PEOPLE, ON ANY OF THE FOLLOWING:

(Y/N)

X OTHER RESOURCES (LIFE ESTATES, UNPROBATED ESTATES, PENSION FUNDS,

TRUSTS, MINERAL RIGHTS, BELONGINGS HELD IN SAFE DEPOSIT BOXES

OR OTHER ITEMS THAT CAN BE TURNED INTO CASH, ETC.)

X BURIAL CONTRACTS OR TRUSTS (FUNDS SET ASIDE FOR BURIAL)

X BURIAL SPACES AND RELATED ITEMS (CEMETERY LOTS, CRYPTS, CASKETS, URNS,

OR OTHER REPOSITORIES FOR BURIAL OR ANY HEADSTONE OR MARKER)

[6-D] [7-D]

X SINCE SS/01/SSSS, HAS SSSSS SSSSSS SSSS SOLD, TRANSFERRED TITLE, DISPOSED

OF OR GIVEN AWAY ANY MONEY OR OTHER PROPERTY, INCLUDING PROPERTY

OR MONEY IN FOREIGN COUNTRIES?

[9-O]

X DISPLAY RESOURCES SUMMARY

IMEN - INCOME MENU (INDIVIDUALS)

MSSICS INCOME MENU PAGE 1 OF IMEN

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

[2-M] [3-D]

SINCE THE FIRST MOMENT OF SS/SS/SSSS, HAVE YOU RECEIVED OR EXPECT TO RECEIVE

INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE SOURCES:

Y/N

X SSI

X STATE OR LOCAL ASSISTANCE BASED ON NEED

X REFUGEE CASH ASSISTANCE

X AFDC

X GENERAL ASST FROM BUREAU OF INDIAN AFFAIRS

X DISASTER RELIEF

X VA BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A DEPENDENT)

X * HAVE YOU RECEIVED ANY OTHER INCOME

X SOCIAL SECURITY

X * HAVE YOU RECEIVED AND EXPECT TO CONTINUE RECEIVING WITHOUT

INTERRUPTION THE PAYMENTS LISTED ABOVE

X * DO YOU MAKE ANY SUPPORT PAYMENTS UNDER A COURT ORDER OR UNDER

TITLE IV-D

MSSICS INCOME MENU PAGE 2 OF IMEN

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO:XXXX

[2-M] [3-D]

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE YOU RECEIVED OR EXPECT TO RECEIVE

INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE SOURCES:

Y/N

X OTHER INCOME BASED ON NEED

X BLACK LUNG

X RAILROAD BOARD BENEFITS

X VA PAYMENTS NOT BASED ON NEED (PAID DIRECTLY OR INDIRECTLY

AS A DEPENDENT)

X OFFICE OF PERSONNEL MANAGEMENT

X PENSION

X UNEMPLOYMENT COMPENSATION

X WORKERS' COMPENSATION

X INTEREST

X DIVIDENDS

X ROYALTIES/HONORARIA (UNEARNED)

X RENTAL/LEASE INCOME NOT FROM A TRADE OR BUSINESS

X ALIMONY

MSSICS INCOME MENU PAGE 3 OF IMEN

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO:XXXX

[2-M] [3-D]

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE YOU RECEIVED OR EXPECT TO RECEIVE

INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE SOURCES:

Y/N

X CHILD SUPPORT

X OTHER BUREAU OF INDIAN AFFAIRS INCOME

X SICK PAY (EARNED)

X SICK PAY (UNEARNED)

X WAGES

X SELF-EMPLOYMENT INCOME prior / current taxable year

X OTHER INCOME OR SUPPORT NOT PREVIOUSLY MENTIONED

G. FACSIMILE 4: IMEN - INCOME MENU

MSSICS INCOME MENU PAGE 4 OF IMEN

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO:XXXX

(Y/N) ADDITIONAL DEVELOPMENT:

[4-O]

X PASS INPUT NEEDED

X SCHOOL INPUT NEEDED

X BLIND COUNTABLE INCOME INPUT NEEDED

[7-O]

X DISPLAY INCOME SUMMARY SCREEN

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE SOURCES

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X SSI

02: 03: 04: 05: 06: 07: 08: 09:

X STATE OR LOCAL ASSISTANCE BASED NEED

01: 02: 03: 04: 05: 06: 07: 08: 09:

X REFUGEE CASH ASSISTANCE

01: 02: 03: 04: 05 06: 07: 08: 09:

X AFDC

01: 02: 03: 04: 05: 06: 07: 08: 09:

X GENERAL ASST FROM BUREAU OF INDIAN AFFAIRS

01: 02: 03: 04: 05: 06: 07: 08: 09:

X DISASTER RELIEF

01: 02: 03: 04: 05: 06: 07: 08: 09:

X VA BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A DEPENDENT)

01: 02: 03: 04: 05: 06: 07: 08: 09:

I. FACSIMILE 6: IMEN - INCOME MENU

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X STATE OR LOCAL ASSISTANCE BASED NEED

10: 11: 12:

X REFUGEE CASH ASSISTANCE

10: 11: 12:

X AFDC

10: 11: 12:

X GENERAL ASST FROM BUREAU OF INDIAN AFFAIRS

10: 11: 12:

X DISASTER RELIEF

10: 11: 12:

X VA BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A DEPENDENT)

10: 11: 12:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X HAVE ANY OF THE LISTED PEOPLE RECEIVED ANY OTHER INCOME

02: 03: 04: 05: 06: 07: 08: 09:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE LISTED PEOPLE RECEIVED

OR EXPECT TO RECEIVE IN THE NEXT 14 MONTHS:

X SOCIAL SECURITY

01: 02: 03: 04: 05: 06: 07: 08: 09:

X HAVE ANY OF THE LISTED PEOPLE RECEIVED AND EXPECT TO CONTINUE TO

RECEIVE WITHOUT INTERRUPTION THE PAYMENTS LISTED ABOVE

02: 03: 04: 05: 06: 07: 08: 09:

X DOES ANYONE MAKE ANY SUPPORT PAYMENTS UNDER A COURT ORDER OR UNDER

TITLE IV-D

02: 03: 04: 05: 06: 07: 08: 09:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X HAVE ANY OF THE LISTED PEOPLE RECEIVED ANY OTHER INCOME

10: 11: 12:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE LISTED PEOPLE RECEIVED

OR EXPECT TO RECEIVE IN THE NEXT 14 MONTHS:

X SOCIAL SECURITY

10: 11: 12:

X HAVE ANY OF THE LISTED PEOPLE RECEIVED AND EXPECT TO CONTINUE TO

RECEIVE WITHOUT INTERRUPTION THE PAYMENTS LISTED ABOVE

10: 11: 12:

X DOES ANYONE MAKE ANY SUPPORT PAYMENTS UNDER A COURT ORDER OR UNDER

TITLE IV-D

10: 11: 12:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X CR WANTS TO DO FULL DEVELOPMENT

02: 03: 04: 05: 06: 07: 08: 09:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X CR WANTS TO DO FULL DEVELOPMENT

10: 11: 12:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X OTHER INCOME BASED ON NEED

01: 02: 03: 04: 05: 06: 07: 08: 09:

X BLACK LUNG

01: 02: 03: 04: 05: 06: 07: 08: 09:

X RAILROAD BOARD BENEFITS

01: 02: 03: 04: 05: 06: 07: 08: 09:

X VA PAYMENTS NOT BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A

DEPENDENT)

01: 02: 03: 04: 05: 06: 07: 08: 09:

X OFFICE OF PERSONNEL MANAGEMENT

01: 02: 03: 04: 05: 06: 07: 08: 09:

X PENSION

01: 02: 03: 04: 05: 06: 07: 08: 09:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X OTHER INCOME BASED ON NEED

10: 11: 12:

X BLACK LUNG

10: 11: 12:

X RAILROAD BOARD BENEFITS

10: 11: 12:

X VA PAYMENTS NOT BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A

DEPENDENT)

10: 11: 12:

X OFFICE OF PERSONNEL MANAGEMENT

10: 11: 12:

X PENSION

10: 11: 12:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATIONS SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X UNEMPLOYMENT COMPENSATION

01: 02: 03: 04: 05: 06: 07: 08: 09:

X WORKERS' COMPENSATION

01: 02: 03: 04: 05: 06: 07: 08: 09:

X INTEREST

01: 02: 03: 04: 05: 06: 07: 08: 09:

X DIVIDENDS

01: 02: 03: 04: 05: 06: 07: 08: 09:

X ROYALTIES/HONORARIA

01: 02: 03: 04: 05: 06: 07: 08: 09:

X RENTAL/LEASE INCOME NOT FROM A TRADE OR BUSINESS

01: 02: 03: 04: 05: 06: 07: 08: 09:

X ALIMONY

01: 02: 03: 04: 05: 06: 07: 08: 09:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X UNEMPLOYMENT COMPENSATION

10: 11: 12:

X WORKERS' COMPENSATION

10: 11: 12:

X INTEREST

10: 11: 12:

X DIVIDENDS

10: 11: 12:

X ROYALTIES/HONORARIA

10: 11: 12:

X RENTAL/LEASE INCOME NOT FROM A TRADE OR BUSINESS

10: 11: 12:

X ALIMONY

10: 11: 12:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N)

X CHILD SUPPORT

01: 02: 03: 04: 05: 06: 07: 08: 09:

X OTHER BUREAU OF INDIAN AFFAIRS INCOME

01: 02: 03: 04: 05: 06: 07: 08: 09:

X SICK PAY RECEIVED (EARNED)

01: 02: 03: 04: 05: 06: 07: 08: 09:

X SICK PAY RECEIVED (UNEARNED)

01: 02: 03: 04: 05: 06: 07: 08: 09:

X WAGES

01: 02: 03: 04: 05: 06: 07: 08: 09:

X SELF-EMPLOYMENT INCOME prior / current taxable year

01: 02: 03: 04: 05: 06: 07: 08: 09:

X OTHER INCOME OR SUPPORT NOT PREVIOUSLY MENTIONED

01: 02: 03: 04: 05: 06: 07: 08: 09:

SINCE THE FIRST MOMENT OF SS/01/SSSS, HAVE ANY OF THE FOLLOWING PEOPLE

RECEIVED OR EXPECT TO RECEIVE INCOME IN THE NEXT 14 MONTHS FROM ANY OF THESE

SOURCES:

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

(Y/N)

X CHILD SUPPORT

10: 11: 12:

X OTHER BUREAU OF INDIAN AFFAIRS INCOME

10: 11: 12:

X SICK PAY RECEIVED (EARNED)

10: 11: 12:

X SICK PAY RECEIVED (UNEARNED)

10: 11: 12:

X WAGES

10: 11: 12:

X SELF-EMPLOYMENT INCOME prior / current taxable year

10: 11: 12:

X OTHER INCOME OR SUPPORT NOT PREVIOUSLY MENTIONED

10: 11: 12:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME RELATION SSSS)

02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME RELATION SSSS)

03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME RELATION SSSS)

(Y/N) ADDITIONAL DEVELOPMENT:

X PASS INPUT NEEDED

01: 02: 03: 04: 05: 06: 07: 08: 09:

X SCHOOL INPUT NEEDED

01: 02: 03: 04: 05: 06: 07: 08: 09:

X BLIND COUNTABLE INCOME INPUT NEEDED

01: 02: 03: 04: 05: 06: 07: 08: 09:

X DISPLAY INCOME SUMMARY SCREEN

01: 02: 03: 04: 05: 06: 07: 08: 09:

01=(NAME RELATION SSSS)

02=(NAME RELATION SSSS)

03=(NAME RELATION SSSS)

(Y/N) ADDITIONAL DEVELOPMENT:

X PASS INPUT NEEDED

10: 11: 12:

X SCHOOL INPUT NEEDED

10: 11: 12:

X BLIND COUNTABLE INCOME INPUT NEEDED

10: 11: 12:

X DISPLAY INCOME SUMMARY SCREEN

10: 11: 12:

BMEN - POTENTIAL ELIGIBILITY FOR OTHER BENEFITS MENU

MSSICS POTENTIAL ELIGIBILITY FOR OTHER BENEFITS MENU BMEN

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

SELECT

(Y/N)

P COMPLETE FOOD STAMPS QUESTIONS

X COMPLETE HEALTH EXPENSES QUESTIONS

DID YOU, YOUR SPOUSE, A FORMER SPOUSE, OR PARENT (IF YOU ARE FILING

AS A CHILD) EVER:

(Y/N)

X SERVE IN THE MILITARY SERVICE

X WORK IN THE RAILROAD INDUSTRY

X WORK FOR THE FEDERAL GOVERNMENT

X WORK FOR A STATE OR LOCAL GOVERNMENT

X BELONG TO A UNION WITH A PENSION PLAN

X WORK FOR A PRIVATE EMPLOYER WITH A PENSION PLAN

X WORK UNDER A SOCIAL SECURITY OR PENSION PLAN

OF A COUNTRY OTHER THAN THE U.S.

BSRD – Retirement and disability entitlement

MSSICS RETIREMENT AND DISABILITY ENTITLEMENT BSRD

SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX

[2-D]

POTENTIAL ENTITLEMENT ON SSN SSS-SS-SSSS

ALREADY ENTITLED TO MAXIMUM BENEFITS (Y/N): X

SELECT REASON NOT ENTITLED: 9 1=NEVER WORKED

2=NO WORK SINCE PRIOR DENIAL

3=REFUSED TO FILE

LEAD STATUS: 9 1=HANDED 2=MAILED 3=FILED

4=SSA OFFICE REFERRAL-NO 8051 5=800 NUMBER REFERRAL