Statement for determining continuing eligibility for Supplemental Security Income Payments -- MISSIC Screens Signature Proxy

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013012
Changes June 2007

SET ASIDE FOR BURIAL OF: 9 [3-M] changed to MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER) (Y/N): X [6-M]

IF OTHER, NAME: [4-C] changed to NAME FOR WHOM SET ASIDE [5-M]

Added information/instruction as follows under NAME FOR WHOM
SET ASIDE due to SET ASIDE FOR BURIAL OF format change: “For
each person’s claim path, the system will compare the name
entered in this field with the name on ACID in order to select
the correct pronoun or name for the SSI printed output (e.g.
application). If the resource is set aside for burial of the
person whose name and SSN display at the top of the screen,
enter the name in this field the same way that it appears on
ACID.”

Changed field name for [2-M] TYPE to [2-M] SELECT TYPE.
SCREEN FACSIMILE 1:
MSSICS
SSS-SS-SSSS

BURIAL FUNDS
SSSSS SSSSSSSSSS

PAGE 1 OF RFND
TRANSFER TO: XXXX

SELECT TYPE: 9
1=BURIAL CONTRACT
2=BURIAL TRUST
DESCRIPTION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
DATE ASSET SET ASIDE (MMDDYY): 999999
NAME FOR WHOM SET ASIDE:
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH FATHER, LIVING WITH MOTHER) (Y/N): X
EARNS INTEREST(Y/N): X
IF EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X
CO-OWNED(Y/N): X
RESOURCE DISPOSAL AGREEMENT (Y/N): X
ANOTHER SOURCE (Y): X

PROOF OF DISPOSAL (Y/N): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS

SSSSS

BURIAL FUNDS
SSSSSSSSSS

PAGE _ OF RFND
TRANSFER TO: XXXX

RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
CO-OWNER
(Y/N) FROM TO
NAME
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
OTHER CO-OWNERS
ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
RESOURCE ID

SSSSS

BURIAL FUNDS
SSSSSSSSSS

PAGE _ OF RFND
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNERS:
FROM
9999
9999
9999
9999

TO
9999
9999
9999
9999

NAME
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

ANOTHER SOURCE (Y): X

SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS

SSSS
SSSS
SSSS
SSSS

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
RESOURCE ID

BURIAL FUNDS
PAGE _ OF RFND
SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
REVOCABLE
IRREVOCABLE
FROM
TO
ALLEGED/
ALLEGED/
LOAN
EXCLUDED COUNTABLE
(MMYY) (MMYY)
VERIFIED
VERIFIED
AMOUNT
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
9999
9999
999999999
999999999
999999999
999999999 SSSSSSSSS
999999999
999999999
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X

REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013004
Changes June 2007
 Changed field [22-M] SET ASIDE FOR BURIAL OF to MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER).
 Changed field [23-C] IF OTHER, NAME to NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
LIFE INSURANCE
PAGE 1 OF RLIF
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
TYPE OF POLICY: 9
1=POLICY WITH CSV (WHOLE LIFE, UNIVERSAL LIFE,
TERM WITH CSV, ETC.)
2=POLICY WITHOUT CSV
NAME OF INSURED: P 1=SAME AS ABOVE
2=OTHER
IF OTHER, SPECIFY: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
FACE VALUE: 999999999
IF POLICY WITH CSV, CSV NEEDED (Y/N): X
COMPANY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
POLICY NUMBER: XXXXXXXXXXXX
DATE PURCHASED (MMDDYY): 999999
POLICY PAYS DIVIDEND ACCUMULATIONS (Y/N): X
IF POLICY HAS CSV AND NO DIVIDEND ACCUMULATIONS,
POLICY PAYS DIVIDEND ADDITIONS (Y/N): X
SET ASIDE FOR BURIAL (Y/N): X
PASS EXCLUSION (Y/N): X
IF TOTALLY EXCLUDED, OWNERSHIP END DATE (MMDDYY): 999999
RESOURCE DISPOSAL AGREEMENT (Y/N): X
PROOF OF DISPOSAL (Y/N): X

ANOTHER SOURCE (Y): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS
RESOURCE ID

LIFE INSURANCE
SSSSS SSSSSSSSSS

PAGE
OF RLIF
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
LIFE INSURANCE
PAGE
OF RLIF
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM
TO
ALLEGED
VERIFIED
LOAN
EXCLUDED
COUNTABLE
(MMYY) (MMYY)
CSV
CSV
AMOUNT
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X
REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013009
Changes June 2007
 Changed [28-M] SET ASIDE FOR BURIAL OF to [29-M] MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER).
 Changed [29-C] IF OTHER, NAME to [28-M] NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS
PAGE 1 OF RNOT
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
TYPE: 9
1=PROMISSORY NOTE/COMMERCIAL LOAN
3=ORAL/INFORMAL LOAN
2=WRITTEN/INFORMAL LOAN
4=PROPERTY AGREEMENT
BORROWER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
PHONE: 999 999 9999
ADDRESS: XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
EARNS INTEREST(Y/N): X
IF TYPE = 2 OR 3 COMPLETE THE FOLLOWING:
DATE OF ORIGINAL LOAN (MMDDYY): 999999
AMOUNT OF ORIGINAL LOAN: 999999999
DESCRIBE COLLATERAL: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IS THERE A TIMETABLE OR PLAN TO REPAY (Y/N): X
HOW DOES BORROWER INTEND TO REPAY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
VALID UNDER STATE LAW (Y/N): X
CO-OWNED(Y/N): X
SET ASIDE FOR BURIAL (Y/N): X
PASS EXCLUSION (Y/N): X
IF TOTALLY EXCLUDED, OWNERSHIP END DATE (MMDDYY): 999999
RESOURCE DISPOSAL AGREEMENT(Y/N): X PROOF OF DISPOSAL(Y/N): X
ANOTHER SOURCE (Y): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS
SSS-SS-SSSS SSSSS SSSSSSSSSS
RESOURCE ID
CO-OWNER
(Y/N) FROM
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X

PAGE _ OF RNOT
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
TO
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999

NAME
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
OTHER CO-OWNERS

ANOTHER SOURCE (Y): X

SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS

SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS
SSS-SS-SSSS SSSSS SSSSSSSSSS
RESOURCE ID

PAGE _ OF RNOT
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNER:
FROM
9999
9999
9999
9999

TO
9999
9999
9999
9999

NAME
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

ANOTHER SOURCE (Y): X

SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS

SSSS
SSSS
SSSS
SSSS

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS
SSS-SS-SSSS SSSSS SSSSSSSSSS
RESOURCE ID

PAGE _ OF RNOT
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999
RESOURCE EARNS INTEREST (Y/N): P
IF RESOURCE EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 5:
MSSICS
PROMISSORY NOTES/LOANS/PROPERTY AGREEMENTS
PAGE _ OF RNOT
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM
TO
ALLEGED
VERIFIED
EXCLUDED
COUNTABLE
(MMYY)
(MMYY)
VALUE
VALUE
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X

REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013011
Changes June 2007
 Changed [22-M] SET ASIDE FOR BURIAL OF to [23-M] MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER).
 Changed [23-C] IF OTHER, NAME to [22-M] NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
OTHER RESOURCES
PAGE 1 OF ROTH
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
TYPE: 9 1=LIFE ESTATE OTHER THAN RESIDENCE
5=TRUST
2=UNPROBATED ESTATE OTHER THAN RESIDENCE 6=RETIREMENT/PENSION FUND
3=BELONGINGS HELD IN SAFE DEPOSIT BOX
7=MINERAL RIGHTS
4=LIFE INSURANCE DIVIDEND ACCUMULATIONS
8=OTHER
IF OTHER, SPECIFY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
DESCRIPTION:

IF
IF
IF
IF

TYPE
TYPE
TYPE
TYPE

=
=
=
=

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

1, 2, 5, 7 OR 8
INCOME FROM PROPERTY
5
DISBURSEMENTS FROM TRUST
5 OR 8
QUALIFIES AS MEDICAID TRUST
4, 5, 6 OR 8
SET ASIDE FOR BURIAL

(Y/N):
(Y/N):
(Y/N):
(Y/N):

X
X
X
X

CO-OWNED (Y/N): X

PASS EXCLUSION (Y/N): X

RESOURCE DISPOSAL AGREEMENT (Y/N): X

PROOF OF DISPOSAL (Y/N): X

ANOTHER SOURCE (Y): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS

OTHER RESOURCES
SSSSS SSSSSSSSSS

PAGE
OF ROTH
TRANSFER TO: XXXX

RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
CO-OWNER
(Y/N) FROM TO
NAME
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
OTHER CO-OWNERS
ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
RESOURCE ID

OTHER RESOURCES
SSSSS SSSSSSSSSS

PAGE
OF ROTH
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNER:
FROM

TO

NAME

9999
9999
9999
9999

9999
9999
9999
9999

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

ANOTHER SOURCE (Y): X

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

XXXX
XXXX
XXXX
XXXX

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
RESOURCE ID

OTHER RESOURCES
SSSSS SSSSSSSSSS

PAGE
OF ROTH
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999
RESOURCE EARNS INTEREST (Y/N): X
IF RESOURCE EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 5:
MSSICS
OTHER RESOURCES
PAGE
OF ROTH
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM
TO
ALLEGED
VERIFIED
LOAN
EXCLUDED
COUNTABLE
(MMYY) (MMYY)
VALUE
VALUE
AMOUNT
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
999999999
SSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X
REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013008
Changes June 2007
 Changed [20-M] SET ASIDE FOR BURIAL OF to [21-M] MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER).
 Changed [21-C] IF OTHER, NAME to [20-M] NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
SSS-SS-SSSS
TYPE: 9

STOCKS AND BONDS
SSSSS SSSSSSSSSS

PAGE 1 OF RSTB
TRANSFER TO: XXXX

1=U.S. SAVINGS BOND (SERIES E AND EE)
2=U.S. SAVINGS BOND (SERIES H AND HH)
3=OTHER BOND
4=STOCK
5=MUTUAL FUND

DESCRIPTION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
IF TYPE IS 2, 3 OR 5, EARNS INTEREST (Y/N): X
IF TYPE IS 4 OR 5, EARNS DIVIDENDS (Y/N): X
CO-OWNED (Y/N): X

PASS EXCLUSION (Y/N): X

SET ASIDE FOR BURIAL (Y/N): X
RESOURCE DISPOSAL AGREEMENT (Y/N): X
ANOTHER SOURCE (Y): X

PROOF OF DISPOSAL (Y/N): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS

STOCKS AND BONDS
SSSSS SSSSSSSSSS

PAGE
OF RSTB
TRANSFER TO: XXXX

RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
CO-OWNER
(Y/N) FROM TO
NAME
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
9999 9999 SSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS
X
OTHER CO-OWNERS

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
RESOURCE ID

STOCKS AND BONDS
SSSSS SSSSSSSSSS

PAGE
OF RSTB
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNER:
FROM

TO

NAME

9999
9999
9999
9999

9999
9999
9999
9999

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

ANOTHER SOURCE (Y): X

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

XXXX
XXXX
XXXX
XXXX

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
RESOURCE ID

STOCKS AND BONDS
SSSSS SSSSSSSSSS

PAGE
OF RSTB
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999
RESOURCE EARNS INTEREST (Y/N): X
IF RESOURCE EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 5:
MSSICS
STOCKS AND BONDS
PAGE
OF RSTB
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM
TO
ALLEGED
VERIFIED
EXCLUDED
COUNTABLE
(MMYY) (MMYY)
VALUE
VALUE
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X
REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS019013
Changes October 2007
 Revised field [2-O] to read: SELECT TO GO TO DETAIL SCREEN: 99
 Changed field [3-D] NUMBER to a 2-position field.
 Added new field [6-O] MORE (Y):
SCREEN FACSIMILE:
MSSICS
POTENTIAL ELIGIBILITY FOR OTHER BENEFITS STATUS
SSS-SS-SSSS SSSSS SSSSSSSSSS
XXXX
SELECT TO GO TO DETAIL SCREEN: 99
NUMBER
SCREEN NAME
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

PAGE 1 OF BLST
TRANSFER TO:

STATUS
S
S
S
S
S
S
S
S
S
S
S
S
S
S

MORE (Y):

MSSICS
POTENTIAL ELIGIBILITY FOR OTHER BENEFITS STATUS
SSS-SS-SSSS SSSSS SSSSSSSSSS
XXXX
SELECT TO GO TO DETAIL SCREEN: 99
NUMBER
SCREEN NAME
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SS
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

PAGE 2 OF BLST
TRANSFER TO:

STATUS
S
S
S
S

http://policynet.ba.ssa.gov/msom.nsf/opentransmittals/791
Changes September 2008
FACSIMILE 3 - IMEN Menu for Individuals:
For field [2-M] 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), modified the wording of one of the
types of income from SELF-EMPLOYMENT INCOME to SELF-EMPLOYMENT
INCOME PRIOR/CURRENT TAXABLE YEAR.
FACSIMILE 15 and S. FACSIMILE 16 – IMEN Menu for Multiples:
For field [8-M] 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, modified the
wording of one of the types of income from SELF-EMPLOYMENT
INCOME to SELF-EMPLOYMENT INCOME PRIOR/CURRENT TAXABLE YEAR

SCREEN FACSIMILE 1:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 1 OF IMEN
TRANSFER TO:

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 REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL SSSS)
(Y/N)
X
X
X
X
X
X
X

SSI
02:
03:
04:
05:
06:
07:
08:
09:
STATE OR LOCAL ASSISTANCE BASED NEED
01:
02:
03:
04:
05:
06:
07:
08:
09:
REFUGEE CASH ASSISTANCE
01:
02:
03:
04:
05:
06:
07:
08:
09:
AFDC
01:
02:
03:
04:
05:
06:
07:
08:
09:
GENERAL ASST FROM BUREAU OF INDIAN AFFAIRS
01:
02:
03:
04:
05:
06:
07:
08:
09:
DISASTER RELIEF
01:
02:
03:
04:
05:
06:
07:
08:
09:
VA BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A DEPENDENT)
01:
02:
03:
04:
05:
06:
07:
08:
09:

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS
XXXX

PUBLIC MAINTENANCE/TITLE IV-D QUESTIONS
SSSSS SSSSSSSSSS

PAGE 2 OF IMEN
TRANSFER TO:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL 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
X

X

X
UNDER

RECEIVED OR EXPECT TO RECEIVE IN THE NEXT 14 MONTHS:
SOCIAL SECURITY
01:
02:
03:
04:
05:
06:
07:
08:
09:
HAVE ANY OF THE LISTED PEOPLE RECEIVED AND EXPECT TO CONTINUE
RECEIVING WITHOUT INTERRUPTION THE PAYMENTS LISTED ABOVE?
02:
03:
04:
05:
06:
07:
08:
09:
DOES ANYONE MAKE ANY SUPPORT PAYMENTS UNDER A COURT ORDER OR
TITLE IV-D?
02:
03:

04:

05:

06:

07:

08:

09:

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU

PAGE 3 OF IMEN
TRANSFER TO:

SSSSS SSSSSSSSSS

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL SSSS)
(Y/N)
CR WANTS TO DO FULL DEVELOPMENT
02:
03:
04:
05:
06:

07:

08:

09:

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 4 OF IMEN
TRANSFER TO:

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 REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL 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:

SCREEN FACSIMILE 5:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 5 OF IMEN
TRANSFER TO:

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 REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL 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:

SCREEN FACSIMILE 6:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 6 OF IMEN
TRANSFER TO:

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 REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL 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 (UNEARNED)
01:
02:
03:
04:
05:
06:
07:
08:
09:
X
SICK PAY RECEIVED (EARNED)
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 INC OR SUPPORT NOT PREVIOUSLY MENTIONED
01:
02:
03:
04:
05:
06:
07:
08:
09:

SCREEN FACSIMILE 7:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 7 OF IMEN
TRANSFER TO:

01=(NAME RELATION SSSS) 04=(NAME RELATION SSSS) 07=(NAME REL SSSS)
02=(NAME RELATION SSSS) 05=(NAME RELATION SSSS) 08=(NAME REL SSSS)
03=(NAME RELATION SSSS) 06=(NAME RELATION SSSS) 09=(NAME REL SSSS)
Y/N Additional Questions:
X
X
X
X

PASS INPUT NEEDED
01:
02:
03:
04:
05:
06:
07:
08:
09:
SCHOOL INPUT NEEDED
01:
02:
03:
04:
05:
06:
07:
08:
09:
BLIND COUNTABLE INCOME NEEDED (WELFARE CONVERSION)
01:
03:
DISPLAY INCOME SUMMARY SCREEEN
01:
02:
03:
04:
05:
06:
07:
08:
09:

SCREEN FACSIMILE 8:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 1 OF IMEN
TRANSFER TO:

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
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 have any support payments under a court order or under
title IV-D
*These questions can appear for an individual who was part of a multiple
menu
but will NOT appear for an individual who was not originally part of a
multiple
menu (i.e. claimant only).

SCREEN FACSIMILE 9:
MSSICS
SSS-SS-SSSS
XXXX

*INCOME MENU
SSSSS SSSSSSSSSS

PAGE 2 OF IMEN
TRANSFER TO:

(Y/N)
CR WANTS TO DO FULL DEVELOPMENT
*This screen can appear for an individual who was part of a multiple menu
but
will NOT appear for an individual who was not originally part of a multiple
menu (i.e. claimant only).

SCREEN FACSIMILE 10:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 3 OF IMEN
TRANSFER TO:

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
X
X
X
X
X
X
X
X
X
X
X
X
X

OTHER INCOME BASED ON NEED
BLACK LUNG
RAILROAD BOARD BENEFITS
VA PAYMENTS NOT BASED ON NEED (PAID DIRECTLY OR INDIRECTLY AS A
DEPENDENT)
SOCIAL SECURITY
OFFICE OF PERSONNEL MANAGEMENT
PENSION
UNEMPLOYMENT COMPENSATION
WORKERS' COMPENSATION
INTEREST
DIVIDENDS
ROYALTIES/HONORARIA
RENTAL/LEASE INCOME NOT FROM A TRADE OR BUSINESS
ALIMONY

SCREEN FACSIMILE 11:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

PAGE 4 OF IMEN
TRANSFER TO:

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
X
X
X
X
X
X

CHILD SUPPORT
OTHER BUREAU OF INDIAN AFFAIRS INCOME
SICK PAY (UNEARNED)
SICK PAY (EARNED)
WAGES
SELF-EMPLOYMENT INCOME PRIOR / CURRENT TAXABLE YEAR
OTHER INC OR SUPPORT NOT PREVIOUSLY MENTIONED

SCREEN FACSIMILE 12:
MSSICS
SSS-SS-SSSS
XXXX

INCOME MENU
SSSSS SSSSSSSSSS

(Y/N) ADDITIONAL QUESTIONS:
X
X
X
X

PASS INPUT NEEDED
01:
SCHOOL INPUT NEEDED
01:
BLIND COUNTABLE INCOME (WELFARE CONVERSION)
01:
DISPLAY INCOME SUMMARY SCREEN:
01:

PAGE 5 OF IMEN
TRANSFER TO:

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS016003

Changes June 2008
 Changed field name for [10-M] from FREQUENCY:
(W,BW,M,SM,BM,Q,SA,A) to FREQ.
 Added new field, [12-C] REPORTED AMOUNT, to page 1 and
page 2 of the IWAG screen.
 Added a separate field for frequency types, [17-C]
FREQUENCY TYPES W=WEEKLY BW=BI-WEEKLY M=MONTHLY SM=SEMIMONTHLY BM=BI-MONTHLY Q=QUARTERLY SA= SEMI-ANNUALLY
A=ANNUALLY.
 FIELD DESCRIPTIONS: Added explanation for field [12-C]
REPORTED AMOUNT.

MSSICS
WAGES
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX

PAGE 1 OF IWAG

EMPLOYER NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX EIN:
999999999
EMPLOYER ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
CONTACT: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PHONE: 999
999 9999
PROJECTION DATE LAST/NEXT PAID SS/SS/SSSS, FREQUENCY SS
FROM TO
FREQ
ALLEGED
REPORTED
VERIFIED
DEDUCTIONS
POSTED
AMOUNT
AMOUNT
AMOUNT
(Y):
AMOUNT
PPPP PPPP
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
IF FREQUENCY IS NOT MONTHLY - DATE LAST/NEXT PAID (MMDDYY):
999999
FREQUENCY TYPES W=WAGES BW=BI-WEEKLY M=MONTHLY SM=SEMIMONTHLY
BM=BI-MONTHLY Q=QUARTERLY SA=SEMI-ANNUALLY
A=ANNUALLY
CONTINUATION SHEET (Y): X
ANOTHER SOURCE(Y): X

DELETE THIS SOURCE(Y): X

REMARKS (Y): X

MSSICS
INCOME CONTINUATION SHEET
OF IWAG
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX

PAGE 2

INCOME TYPE: SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM TO
FREQ
ALLEGED
REPORTED
VERIFIED
DEDUCTIONS
POSTED
AMOUNT
AMOUNT
AMOUNT
(Y):
AMOUNT
PPPP PPPP
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
9999 9999
XX
99999999
99999999
99999999
X
SSSSSSSS
IF FREQUENCY IS NOT MONTHLY - DATE LAST/NEXT PAID (MMDDYY):
999999
FREQUENCY TYPES W=WAGES BW=BI-WEEKLY M=MONTHLY SM=SEMIMONTHLY
BM=BI-MONTHLY Q=QUARTERLY SA=SEMI-ANNUALLY
A=ANNUALLY
ANOTHER CONTINUATION SHEET (Y): X
ANOTHER SOURCE (Y): X
REMARKS (Y): X

MSSICS
DEDUCTIONS
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
GARNISHED
FOR COURT
ORDERED
BEFORE
OR IV-D
DEDUCTION
SUPPORT
FROM
TO
AMOUNT
AMOUNT:
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
SS/SS SS/SS SSSSSSSSS
99999999
OTHER DEDUCTION AMOUNT REASON:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
MORE (Y): S
REMARKS (Y): X
MORE (Y): S
REMARKS (Y): X

PAGE S OF IWAG

OTHER
DEDUCTION
AMOUNT:
99999999
99999999
99999999
99999999
99999999
99999999
99999999
99999999
99999999
99999999

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013013
Changes June 2007
 RELATIONSHIP TO CLAIMANT [5-O] changed to MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, MOTHER, FATHER, MOTHER’S SPOUSE,
FATHER’S SPOUSE, CHILD, CHILD’S SPOUSE, SIBLING, SIBLING’S
SPOUSE) (Y/N): X [5-M]
 Changed naming convention for field [4-M] NAME FOR WHOM HELD
(separate input lines for first name, middle name, last name,
and suffix)
 Removed field [6-O] IF OTHER, SPECIFY RELATIONSHIP.
 Changed all field numbers subsequent to IF OTHER, SPECIFY
RELATIONSHIP down by 1.
SCREEN FACSIMILE 1:
MSSICS
SSS-SS-SSSS

BURIAL SPACES AND RELATED ITEMS
SSSSS SSSSSSSSS

SELECT ITEM: 9

1=CEMETERY LOT
5=HEADSTONE

2=CRYPT
6=MARKER

3=CASKET
7=OTHER

PAGE 1 OF RBSI
TRANSFER TO: XXXX
4=URN

IF OTHER, SPECIFY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE, MOTHER, FATHER,
MOTHER’S SPOUSE, FATHER’S SPOUSE, CHILD, CHILD’S SPOUSE, SIBLING,
SIBLING’S SPOUSE) (Y/N): X

CO-OWNED (Y/N): X
RESOURCE DISPOSAL AGREEMENT(Y/N): X
ANOTHER SOURCE (Y): X

PROOF OF DISPOSAL(Y/N): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS
RESOURCE ID
CO-OWNER
(Y/N) FROM
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X

BURIAL SPACES AND RELATED ITEMS
SSSSS SSSSSSSSSS

PAGE _ OF RBSI
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
TO
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999

NAME
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
OTHER CO-OWNERS

ANOTHER SOURCE (Y): X

SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS

SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
RESOURCE ID

BURIAL SPACES AND RELATED ITEMS
SSSSS SSSSSSSSSS

PAGE _ OF RBSI
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNERS:
FROM
S
9999
9999
9999
9999

TO

NAME

9999
9999
9999
9999

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

ANOTHER SOURCE (Y): X

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

XXXX
XXXX
XXXX
XXXX

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
RESOURCE ID
FROM
(MMYY)
PPPP
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999

BURIAL SPACES AND RELATED ITEMS
PAGE _ OF RBSI
SSSSS
SSSSSSSSSS
TRANSFER TO: XXXX
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

TO
(MMYY)
PPPP
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999

ALLEGED
VALUE
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999

VERIFIED
VALUE
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999

LOAN
AMOUNT
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999

EXCLUDED
AMOUNT
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999
999999999

EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X

COUNTABLE
AMOUNT
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS
SSSSSSSSS

REMARKS (Y): X

http://policynet.ba.ssa.gov/msom.nsf/lnx/MSSICS013006
Changes June 2007
 Changed [13-M] SET ASIDE FOR BURIAL OF to [14-M] MEETS
EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER,
LIVING WITH FATHER).
 Changed [14-C] IF OTHER, NAME to [13-M] NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
CASH
PAGE 1 OF RCSH
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO:
XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
SET ASIDE FOR BURIAL (Y/N): X
PASS EXCLUSION (Y/N): X
FROM
TO
ALLEGED
EXCLUDED
COUNTABLE
(MMYY)
(MMYY)
VALUE
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CONTINUATION SHEET (Y): X
REMARKS
(Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS
XXXX
RESOURCE ID

CASH
SSSSS SSSSSSSSSS

PAGE
OF RCSH
TRANSFER TO:

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

FROM
TO
ALLEGED
EXCLUDED
COUNTABLE
(MMYY)
(MMYY)
VALUE
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
9999
9999
999999999
999999999
SSSSSSSSSS
EXCLUSION REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CONTINUATION SHEET (Y): X
REMARKS
(Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
XXXX
RESOURCE ID

CASH
SSSSS SSSSSSSSSS

PAGE _ OF RCSH
TRANSFER TO:

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999

http://policynet.ba.ssa.gov/msom.nsf/opentransmittals/699
Changes June 2007
 Changed [22-M] SET ASIDE FOR BURIAL OF to [23-M] MEETS EXCLUSION
RELATIONSHIP (CLAIMANT, SPOUSE, LIVING WITH MOTHER, LIVING WITH
FATHER).
 Changed [23-C] IF OTHER, NAME to [22-M] NAME FOR WHOM HELD.
SCREEN FACSIMILE 1:
MSSICS
FINANCIAL INSTITUTION ACCOUNTS
PAGE 1 OF RFIA
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
TYPE OF ACCOUNT: 9
1=CHECKING
5=TIME DEPOSIT
2=SAVINGS
6=INDIVIDUAL INDIAN MONEY ACCOUNT
3=CREDIT UNION
7=OTHER
4=CHRISTMAS CLUB
IF OTHER, SPECIFY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
EARNS INTEREST (Y/N): X
ACCOUNT NUMBER: 99999999999999999999
INSTITUTION NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXX
CO-OWNED (Y/N): X

SET ASIDE FOR BURIAL (Y/N): X

RESOURCE DISPOSAL AGREEMENT (Y/N): X
ANOTHER SOURCE (Y): X

PASS EXCLUSION (Y/N): X

PROOF OF DISPOSAL (Y/N): X

DELETE THIS SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 2:
MSSICS
SSS-SS-SSSS
RESOURCE ID
CO-OWNER
(Y/N) FROM
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X
9999
X

FINANCIAL INSTITUTION ACCOUNTS
SSSSS SSSSSSSSSS

PAGE
OF RFIA
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
TO
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999

NAME
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
OTHER CO-OWNERS

ANOTHER SOURCE (Y): X

SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS
SSSSSSSSSSSSSSS

SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS
SSSSSSSSSSSSSSSSSSSS

SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS
SSSS

REMARKS (Y): X

SCREEN FACSIMILE 3:
MSSICS
SSS-SS-SSSS
RESOURCE ID

FINANCIAL INSTITUTION ACCOUNTS
SSSSS SSSSSSSSSS

PAGE
OF RFIA
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

SPECIFY OTHER CO-OWNERS:
FROM
9999
9999
9999
9999

TO
9999
9999
9999
9999

NAME
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

ANOTHER SOURCE (Y): X

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

XXXX
XXXX
XXXX
XXXX

REMARKS (Y): X

SCREEN FACSIMILE 4:
MSSICS
SSS-SS-SSSS
RESOURCE ID

FINANCIAL INSTITUTION ACCOUNTS
SSSSS SSSSSSSSSS

PAGE
OF RFIA
TRANSFER TO: XXXX

SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS

NAME FOR WHOM HELD: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
MEETS EXCLUSION RELATIONSHIP (CLAIMANT, SPOUSE,
LIVING WITH MOTHER, LIVING WITH FATHER) (Y/N): X
DATE ASSET SET ASIDE (MMDDYY): 999999

RESOURCE EARNS INTEREST (Y/N): X
IF RESOURCE EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X

ANOTHER SOURCE (Y): X

REMARKS (Y): X

SCREEN FACSIMILE 5:
MSSICS
FINANCIAL INSTITUTION ACCOUNTS
PAGE
OF RFIA
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
RESOURCE ID SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
FROM
TO
ALLEGED
VERIFIED
EXCLUDED
COUNTABLE
(MMYY) (MMYY)
VALUE
VALUE
AMOUNT
AMOUNT
PPPP
PPPP
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
9999
9999
999999999
999999999
999999999
SSSSSSSSS
EXCLUSION REASON:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
ANOTHER SOURCE (Y): X
CONTINUATION SHEET (Y): X
REMARKS (Y): X