Marital Relationship Questionnaire

[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
OTHER PERSON'S NAME: VVVVVVVVVVVVVVV VVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVV VVVV
[3-C]
OTHER PERSON'S SSN: VVVVVVVVV
[4-M]
ALLEGE HOLDING OUT AS COUPLE TO COMMUNITY (Y/N): X
[5-O]
DEVELOPMENT NEEDED (Y): X
[6-C]
IF YES,
NAME YOU ARE KNOWN BY TO COMMUNITY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[7-C]
HOW YOU INTRODUCE THE OTHER PERSON:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[8-C]
HOW MAIL IS ADDRESSED TO YOU
:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[9-C]
BILLS ADDRESSED AS HUSBAND AND WIFE (Y/N): X
[10-C]
RESIDENCE OWNED OR RENTED BY BOTH (Y/N): X
[11-C]
IF YES, NAME ON DEED OR LEASE:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[12-M]
[13-C]
CONSIDER AS A COUPLE FOR SSI (Y/N): B
VERIFIED (Y/N): X
[14-C]
IF NO, EXPLAIN:
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
[15-C]
IF YES, HOLDING OUT BEGIN DATE (MMDDCCYY): PPPPPPPP
[16-O]
END DATE (MMDDCCYY): PPPPPPPP
[17-O]
[18-O]
ANOTHER RELATIONSHIP (Y): X

[19-O]
DELETE THIS SOURCE (Y): X

REMARKS (Y): X