Application for Supplemental Security Income MSSICS/Signature Proxy

8001Screens2009
FACSIMILE: ACLM - SSI CLAIMS APPLICATION
MSSICS
SSI CLAIMS APPLICATION
ACLM
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
APPLICATION TYPE: P 1=DEFERRED 2=FULL 3=ABBREVIATED
[3-C]
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
[5-M]
EFFECTIVE FILING DATE (MMDDYY): 999999
[6-O]
PENDING FILE BEGIN DATE (MMYY): SSSS
[7-M]
TYPE OF APPLICANT: P 1=CLAIMANT 2=OTHER INDIVIDUAL 3=AGENCY

FACSIMILE: 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
[2-M]
FOR WRITTEN COMMUNICATION: PP
1. ENGLISh
16. ARABIC
31.CHINESETOISHANESE
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)

FACSIMILE: ACID - CLIENT IDENTIFICATION
MSSICS
CLIENT IDENTIFICATION
ACID
[1-O]
SSS-SS-SSSS
TRANSFER TO: XXXX
[2-M]
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
[8-C]
[9-C]
[7-M]
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
[12-O]
MOTHER'S MAIDEN NAME: PPPPPPPPPPPPPPP PPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPP PPPP
[13-O]
FATHER'S NAME: PPPPPPPPPPPPPPP PPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPP PPPP
[15-O]
[16-O]
[14-O]
DATE OF DEATH (MMDDCCYY): PPPPPPPP PROOF (Y/N): X REMOVE
DEATH (Y): X
[17-O]
SOURCE OF NOTIFICATION: P 1=FO 2=EDR 3=MBR 4=TREASURY

FACSIMILE 1: AMAR - MARRIAGE DATA
MSSICS
MARRIAGE DATA
PAGE 1 OF AMAR
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
SPOUSE NAME: VVVVVVVVVVVVVVV VVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVV VVVV
[3-C]
SPOUSE SSN: VVVVVVVVV
[4-C]
LIVING TOGETHER SINCE SS/SS/SSSS (Y/N): X
[5-C]
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

FACSIMILE: ADIB - DISABILITY DATA
MSSICS
DISABILITY DATA
ADIB
[1-O]
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:
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVV
[5-M]
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
[10-O]
TERMINAL CASE INDICATOR (Y/N): X

FACSIMILE: ACIT - CITIZENSHIP
MSSICS
CITIZENSHIP
ACIT
[1-O]
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
[3-C]
DATE OF CHANGE (MMDDYY): 999999
[4-C]
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-C]
5=OTHER TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[6-C]
[7-O]
CITIZENSHIP CHANGE (Y): X
PRE-1/1/79 RECORD (Y/N): X

FACSIMILE 1: AALN - ALIEN DATA
MSSICS
ALIEN DATA
PAGE 1 OF AALN
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
[3-M]
U.S. ENTRY DATE (MMDDCCYY): PPPPPPPP
COUNTRY OF ORIGIN:
XX
[4-M]
[5-O]
ALIEN STATUS CODE: X
ALIEN STATUS VERIFIED (Y/N): X
[6-M]
GRANDFATHERED ALIEN (Y/N): X
[7-C]
IF CODE K, S, Y OR 3, DATE OF LAPR (MMDDCCYY): 99999999
[8-C]
IF CODE F, REFUGEE PER SECTION 207 (Y/N): X
[9-C]
IF CODE L, ASYLEE STATUS GRANTED DATE (MMDDYY): 999999
[10-C]
IF CODE X AND CUBAN/HAITIAN ENTRANT, DATE GRANTED (MMYY): 9999
[11-C]
IF CODE G OR X, PAROLEE STATUS GRANTED FOR 1 YEAR OR MORE (Y/N):
X
[12-O]
IF CODE J AND SECTION 243(H), 241(B)(3),
DEPORTATION WITHHELD DATE (MMDDYY): 999999
[13-C]
IF CODE Z, BATTERY PETITION FILED (Y/N): X
[14-O]
[15-C]
[16-C]
EXCEPTION MET: 9
FROM (MMDDYY): 999999
TO: (MMDDYY):
999999
1=ACTIVE DUTY MILITARY/VETERAN
3=CHILD OF
MILITARY/VETERAN
2=SPOUSE/WIDOW(ER) OF MILITARY/VETERAN
[17-C]
IF EXCEPTION 2 OR 3, MILITARY/VETERAN SSN: 999999999
[18-C]
IF CODE K, S, Y OR 3 OR NEW VERSION AFFIDAVIT IN EFFECT,
40 QCS CREDITED (Y/N): X [19-C]
IF YES, DATE MET (MMYY): 9999
[20-C]
[21-C]

QCS FROM ANOTHER WORKER (Y/N): X IF YES, WORKER SSN: 999999999
[22-D]
[24-O]
[23-C]
SPONSORED AT ANY TIME SINCE SS/SS/SSSS (Y/N): X
REMARKS

FACSIMILE: ARES - RESIDENCY/PRESENCE IN U.S.
MSSICS
RESIDENCY/PRESENCE IN U.S.
ARES
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
RESIDENT OF THE U.S. (Y/N): X
[3-C]
IF YES, FIRST U.S. RESIDENCY DATE (MMDDCCYY): PPPPPPPP
[4-C]
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
99999999
99999999
[7-D]
[8-C]
CONTINUOUS PRESENCE IN U.S. SINCE SS/SS/SSSS (Y/N): X
[9-C]
[10-C]
IF NO,
LEFT (MMDDCCYY):
RETURNED (MMDDCCYY):
99999999
99999999
99999999
99999999

FACSIMILE: AWRF - FELONY WARRANT
MSSICS
FELONY WARRANT
AWRF
[1-O]
SSS-SS-SSSS
TRANSFER TO: XXXX
[2-M]
DATE WARRANT ISSUED (MMDDYY): 999999
[3-O]
DATE FLED (MMDDYY): 999999
[4-M]
WARRANT SELECTED/ISSUED IN ERROR (Y/N): X
[5-C]
WARRANT SATISFIED (Y/N): X
[6-C]
IF YES, DATE WARRANT SATISFIED (MMDDYY): 999999
[7-C]
GOOD CAUSE: 9 1=ESTABLISHED
2=NOT ESTABLISHED

FACSIMILE: AWRP - PAROLE OR PROBATION VIOLATION WARRANT
MSSICS
PAROLE OR PROBATION VIOLATION WARRANT
AWRP
[1-O]
SSS-SS-SSSS
TRANSFER TO: XXXX
[2-M]
DATE WARRANT ISSUED (MMDDYY): 999999
[3-O]
DATE VIOLATED PAROLE OR PROBATION (MMDDYY): 999999
[4-M]
WARRANT SELECTED/ISSUED IN ERROR (Y/N): X
[5-C]
WARRANT SATISFIED (Y/N): X
[6-C]
IF YES, DATE WARRANT SATISFIED (MMDDYY): 999999
[7-C]
GOOD CAUSE: 9 1=ESTABLISHED
2=NOT ESTABLISHED
[8-O]
[9-O]
[10-O]

FACSIMILE: ALEF - LAW ENFORCEMENT
MSSICS
LAW ENFORCEMENT
ALEF
[1-O]
SSS-SS-SSSS
TRANSFER TO: XXXX
[2-M]
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
[6-C]
[5-D]
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
[10-C]
[9-D]
SINCE SS/SS/SSSS, FEDERAL OR STATE ARREST WARRANT FOR PAROLE
OR
PROBATION VIOLATION(Y/N): X

LRES - RESIDENCE ADDRESS
MSSICS
RESIDENCE ADDRESS
PAGE 1 OF LRES
[1-D]
[2-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER
TO: XXXX
[3-M]
ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP
[5-O] [6-C]
[4-M]
CITY: PPPPPPPPPPPPPPPPPPPPPP STATE: PP ZIP: PPPPP
[7-O]
[8-O]
COUNTY: XXXXXXXXXXXXXXXXXX COUNTRY:
PPPPPPPPPPPPPPPPPPPPPP
[10-O]
[9-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)

RMEN - RESOURCES MENU
MSSICS
RESOURCES MENU
PAGE 1 OF RMEN
SSSSSSSSS SSSSS SSSSSSSSS
[1-D]
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]
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
[5-M]
(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

FACSIMILE 1: RFND - BURIAL FUNDS
MSSICS
BURIAL FUNDS
PAGE 1 OF RFND
[1-O]
SSSSSSSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
select TYPE: 9 1=BURIAL CONTRACT 2=BURIAL TRUST
[3-M]
DESCRIPTION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[4-M]
DATE ASSET SET ASIDE (MMDDYY): 999999
[5-M]
name for whom set aside:
xxxxxxxxxxxxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxx
[6-M]
meets exclusion relationship (claimant, spouse,
living with mother, living with father) (y/n): X
[7-M]
EARNS INTEREST (Y/N): X
[8-C]
IF EARNS INTEREST, INTEREST REMAINS IN FUND (Y/N): X
[9-O]
CO-OWNED (Y/N): X
[10-O]
[11-O]
RESOURCE DISPOSAL AGREEMENT (Y/N): X PROOF OF DISPOSAL (Y/N): X
[13-O]
[14[12-O]

FACSIMILE: RGIV - PROPERTY/CASH GIVEN OR SOLD
MSSICS
PROPERTY/CASH GIVEN OR SOLD
RGIV
[1-O]
SSSSSSSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
DESCRIPTION OF PROPERTY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
X
[3-M]
RECEIVER NAME:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[4-M]
ADDRESS: XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXX
XXXXXX
XXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX
XX
[5-M]
RELATIONSHIP TO NEW OWNER: 9 1=NONRELATIVE
2=RELATIVE
[6-M]
[7-M]
TRANSFER DATE (MMDDYY): 999999 MARKET VALUE OR AMOUNT OF CASH
GIFT: 999999999
[8-M]
NATURE OF TRANSFER: 9 1=SOLD ON OPEN MARKET 3=EXCHANGED FOR
GOODS OR SERVICES
2=GIVEN AWAY
4=OTHER
[9-C]
IF SOLD, SALES PRICE: 999999999
[10-C]
IF EXCHANGED FOR GOODS OR SERVICES,
SPECIFY GOODS/SERVICES RECEIVED:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[11-C]
IF OTHER, EXPLAIN NATURE OF
TRANSFER:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[12-M]
ADDITIONAL CONSIDERATIONS OR PROCEEDS EXPECTED (Y/N): X
[13-C]
EXPLAIN CONSIDERATIONS OR PROCEEDS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[14-M]

STILL OWN PART OF PROPERTY (Y/N): X
[16-O]
[17-O]
[15-O]
ANOTHER SOURCE (Y): X

IMEN - INCOME MENU (INDIVIDUALS)
MSSICS
INCOME MENU
PAGE 1 OF IMEN
[1-O]
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
FACSIMILE 2: IMEN - INCOME MENU
E.
MSSICS
INCOME MENU
PAGE 2 OF IMEN
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO:XXXX
[3-D]
[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
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
F.
FACSIMILE 3: IMEN - INCOME MENU
MSSICS
INCOME MENU
PAGE 3 OF IMEN
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO:XXXX
[3-D]
[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
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

BFDS - FOOD STAMPS
MSSICS
FOOD STAMPS
PAGE 1 OF BFDS
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
FOOD STAMPS STATUS: 9
(CHOOSE ONE):
1 = CURRENTLY RECEIVING FOOD STAMPS
2 = FILED WITHIN THE PAST 60 DAYS
3 = NEVER FILED OR FILE DATE MORE THAN 60 DAYS IN PAST
D.
FACSIMILE 2: BFDS - FOOD STAMPS
MSSICS
FOOD STAMPS
PAGE 2 OF BFDS
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[3-M]
RECERTIFICATION NOTICE RECEIVED WITHIN PAST 30 DAYS (Y/N): X
[4-C]
IF YES, ALL HOUSEHOLD MEMBERS APPLYING FOR OR RECEIVING SSI
(Y/N/P): X
[5-C]
IF YES OR PRERELEASE, MAY I TAKE YOUR FOOD STAMP APPLICATION
TODAY? (Y/N): X
[6-C]
IF NO,
EXPLAIN: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

FACSIMILE: APLC - APPLICANT DATA
MSSICS
APPLICANT DATA
APLC
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-C]
PERSON: XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX XXXX
[3-C]
SSN: 999999999
[5-C]
[4-C]
AGENCY:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX EIN:
999999999
[6-M]
RELATIONSHIP TO CLAIMANT: P
1=NATURAL OR ADOPTIVE MOTHER
WITH CUSTODY
2=NATURAL OR ADOPTIVE FATHER WITH CUSTODY
3=NATURAL OR ADOPTIVE PARENT WITHOUT CUSTODY
4=STEPPARENT
5=LIVING WITH SPOUSE
[7-C]
6=OTHER

FACSIMILE: ADDR - MAILING/PAYMENT ADDRESS
MSSICS
MAILING/PAYMENT ADDRESS
PAGE 1 OF ADDR
[1-O]
SSS-SS-SSSS SSSSS SSSSSSSSSS
TRANSFER TO: XXXX
[2-M]
ADDR: PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
PPPPPPPPPPPPPPPPPPPPPP
[4-C]
[5-C]
[3-M]
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
[11-O]
[10-O]
DOMESTIC PHONE NO: PPP PPP PPPP
FOREIGN PHONE NO:
PPPPPPPPPPPPPPP
[12-O]
PHONE INFO: XXXXXXXXXX
[13-O]
EXPLAIN C/O ADDRESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
X
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXX
[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-C]
SELECT NOTICE OPTION: 9
1=REGULAR 3=REGULAR W/FOLLOWUP PHONE CONTACT
2=CERTIFIED 4=BRAILLE

[9-O]
[8-O]
ANOTHER WARRANT (Y): X

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