Statement of Living Arrangements, In-Kind Support and Maintenance

Statement of Living Arrangements, In-Kind Support and Maintenance

MSSICS SCREEN PRINTS for SSA 8006

Statement of Living Arrangements, In-Kind Support and Maintenance

OMB: 0960-0174

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MSSICS SCREEN PRINTS FOR


OMB # 0960-0174


SSA-8006-F4


The following are screen prints from the Modernized SSI Claim System (MSSICS) that collect information that is equivalent to the paper form SSA-8006-F4. Like the SSA-8006-F4, these MSSICS screens collect information that is needed to establish whether the SSI beneficiary lives in his or her own household or lives in another person’s household. Like the SSA-8006-F4, these screens also collect information that is needed to determine if the SSI beneficiary receives in-kind support and maintenance from inside the household, from outside the household, or does not receive any in-kind support and maintenance.



LXHP Screens (Householder In-Kind Support and Maintenance/Cash Income)


The LXHP screens collect information to determine in-kind support and maintenance when an SSI beneficiary is considered to be living in his or her own household and has roommates who contribute to paying the household’s expenses.


LOHH Screens (In-Kind Support and Maintenance Provided in the Household of Another)


The LOHH screens collect information to determine in-kind support and maintenance when an SSI beneficiary lives in the household of another and may be receiving food and shelter paid for by the other members of the household.


LISM Screens (In-Kind Support and Maintenance Received from Outside the Household)


The LISM screens collect information to determine whether the SSI beneficiary is getting in-kind support and maintenance because the beneficiary gets food or shelter provided by third parties outside the household.




MSSICS                HOUSEHOLDER ISM/CASH DATA             PAGE 1 OF LXHP

                                 [1-D]                       [2-O]

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

[3-M]

DO OTHERS CONTRIBUTE TO HOUSEHOLD EXPENSES (Y/N): X

[4-C]

EAT ALL MEALS OUT(Y/N): X

    [5-C]

    IF NO, BUY FOOD SEPARATE FROM HOUSEHOLD (Y/N): X

[6-C]                                           [7-C]

CONTRIBUTION AVERAGE PERIOD FROM (MMYY): PPPP   TO (MMYY): PPPP

          [8-C]

          AMOUNT OTHERS CONTRIBUTE:    9999999

          [9-C]

          MONTHLY LOAN AMOUNT:         9999999

          [10-C]

          AMOUNT CLAIMANT CONTRIBUTES: 9999999                  [11-O]

                                                                REMARKS (Y): X





MSSICS                HOUSEHOLDER ISM/CASH DATA               PAGE 2 OF LXHP

                                 [1-D]                       [2-O]

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

[12-M]                                   [13-M]

EXPENSE AVERAGE PERIOD FROM (MMYY): PPPP  TO (MMYY): PPPP

    FOR THE PERIOD ABOVE, COLLECT THE FOLLOWING MONTHLY EXPENSES

                          [14-M]                        [15-M]

                          FOOD: 9999999                 MORTGAGE/RENT: PPPPPPP

            [16-C]                                     [17-C]

            PROPERTY INSURANCE: 9999999                PROPERTY TAXES: 9999999

                  [18-M]                                  [19-M]

                  HEATING FUEL: 9999999                   ELECTRICITY: 9999999

                           [20-M]                     [21-M]

                           GAS: 9999999               GARBAGE REMOVAL: 9999999

                         [22-M]                                [23-M]

                         WATER:  9999999                       SEWER: 9999999

                                     [24-D]

                                     TOTAL EXPENSES: SSSSSSS

                                     [25-D]

                                     PRO RATA SHARE: SSSSSSS

                                                              [11-O]

                                                              REMARKS (Y): X



MSSICS               HOUSEHOLDER ISM/CASH DATA             PAGE 3  OF LXHP

                                 [1-D]                       [2-O]

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

     [26-D]                 [27-M]             [28-D]             [29-D]

     DEEMOR                 AMOUNT DEEMOR      EXCESS FROM        CLAIMANT'S

                            CONTRIBUTES:       DEEMOR             SHARE

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   SSSSS SSSSSSSSS            9999999          SSSSSSS            SSSSSSS

   [30-D]                             [31-D]

   TOTAL FOR CLAIMANT: SSSSSSSS       CLAIMANT'S EXCESS:  SSSS.SS

   [32-D]                            [33-D]

   INSIDE ISM TO CLAIMANT: SSSSSSS   CASH FROM WITHIN THE HOUSEHOLD: SSSSSSS

   [34-C]

   CONTRIBUTION VERIFICATION REQUIRED - RECEIVED(Y/N): X      [11-O]

                                                              REMARKS (Y): X







MSSICS                    HOUSEHOLD OF ANOTHER                 PAGE 1 OF LOHH

                                [1-D]                     [2-O]

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

[3-M]

 EAT ALL MEALS OUT (Y/N): X

    [4-C]

    IF NO, BUY FOOD SEPARATE FROM HOUSEHOLD (Y/N): X

 [5-C]

 WISH TO REBUT PMV (Y/N): X

 [6-C]

 CLAIMANT/DEEMOR CONTRIBUTE TOWARD HOUSEHOLD EXPENSES (Y/N): X

    [7-C]

    CLAIMANT MAKES TOKEN CONTRIBUTION (Y/N): X

    [8-C]

    DEEMOR MAKES TOKEN CONTRIBUTION (Y/N): X

[9-C]                                            [10-C]

CONTRIBUTION AVERAGE PERIOD FROM (MMYY): PPPP    TO (MMYY): PPPP

    [11-C]

    MONTHLY LOAN AMOUNT:     9999999

    [12-C]

    CLAIMANT'S CONTRIBUTION: 9999999




MSSICS                   HOUSEHOLD OF ANOTHER                   PAGE 2 OF LOHH

                                [1-D]                       [2-O]

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

 [14-M]                                           [15-M]

EXPENSE AVERAGE PERIOD FROM (MMYY): PPPP         TO (MMYY): PPPP

    FOR THE PERIOD SHOWN, COLLECT THE FOLLOWING MONTHLY EXPENSES

                        [16-C]                    [17-M]

                        FOOD: 9999999             MORTGAGE/RENT: PPPPPPP

          [18-C]                                 [19-C]

          PROPERTY INSURANCE: 9999999            PROPERTY TAXES:  9999999

                [20-M]                              [21-M]

                HEATING FUEL: 9999999               ELECTRICITY:  9999999

                         [22-M]                 [23-M]

                         GAS: 9999999           GARBAGE REMOVAL:   9999999

                       [24-M]                             [25-M]

                       WATER: 9999999                     SEWER:  9999999

                                [26-D]

                                TOTAL EXPENSES: SSSSSSS

                                [27-D]

                                PRO RATA SHARE: SSSSSSS

                                [28-C]

                                CONTRIBUTION VERIFIED (Y/N):  Y

                                                          [13-O]

                                                          REMARKS (Y): X




MSSICS                  HOUSEHOLD OF ANOTHER                   PAGE 3 OF LOHH

                                [1-D]                      [2-O]

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

EARMARK OPTIONS  1=NOT EARMARKED   2=FOOD  3=SHELTER  4=BOTH FOOD  SHELTER

 [29-D]                [30-M]          [31-M]      [32-D]         [33-D]

 DEEMOR                CONTRIBUTION:   EARMARKED   EXCESS FROM    CLAIMANT'S

                                                   DEEMOR         SHARE

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

 SSSSS SSSSSSSSS         9999999          9        SSSSSSS        SSSSSSS

                       [34-D]

                       TOTAL FOR CLAIMANT: SSSSSSS

                                                           [13-O]

                                                           REMARKS (Y): X





MSSICS                   HOUSEHOLD OF ANOTHER                  PAGE   OF LOHH

                                  [1-D]                     [2-O]

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

                         [34-D]

                         TOTAL FOR CLAIMANT:  SSSSSSS

             [35-M]

             CLAIMANT'S CONTRIBUTION EARMARKED FOR: 9   1=NOT EARMARKED

                                                        2=FOOD ONLY

                                                        3=SHELTER ONLY

                                                        4=BOTH FOOD  SHELTER

         [36-C]                      [37-C]

         IF 4, FOOD AMOUNT: 9999999  SHELTER AMOUNT: 9999999

                   [38-D]                [39-D]

                   FOOD SHARE: SSSSSSS   SHELTER SHARE: SSSSSSS

                         [40-D]

                         TOTAL ISM FROM HOUSEHOLD: SSSSSSS

                   [41-C]

                   EARMARKED CONTRIBUTION VERIFIED (Y/N):  X

                                                               [13-O]

                                                               REMARKS (Y): X



VERSION 1

MSSICS                        ISM                              PAGE 1 OF LISM

                                 [1-D]                      [2-O]

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

[3-M]

PERSON RECEIVING ISM: 9   1=SSSSS SSSSSSSSS

                          2=SSSSS SSSSSSSSS

                          3=BOTH EQUALLY

 [4-M]

SOURCE NAME:     PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS:  PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

                 PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

[6-C]                             [7-C]

ISM COUNTABLE (Y/N): P            IF NO, REASON:

[8-C]                                  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

TYPE OF ISM: P   1=FOOD

                 2=SHELTER

                 3=CLOTHING/ISM TO ONE

                 4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

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

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



VERSION 2

MSSICS                           ISM                           PAGE 1 OF LISM

                                 [1-D]                      [2-O]

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

 [13-M]

DOES ISM HAVE VALUE (Y/N): X

[14-M]

IF TRANSIENT,  WISH TO REBUT PMV (Y/N): X

[4-M]

SOURCE NAME:     PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS:  PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

                 PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

[6-C]                            [7-C]

ISM COUNTABLE (Y/N): P           IF NO, REASON:

[8-C]                                          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

TYPE OF ISM: P   1=FOOD

                 2=SHELTER

                 3=CLOTHING/ISM TO ONE

                 4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

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

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



VERSION 3

MSSICS                           ISM                           PAGE 1 OF LISM

                                 [1-D]                      [2-O]

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

 [4-M]

SOURCE NAME:     PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS:  PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

                 PPPPPPPPPPPPPPPPPPPPPP   PPPPPPPPPPPPPPPPPPPPPP

[6-C]                           [7-C]

ISM COUNTABLE (Y/N): P          IF NO, REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[8-C]

TYPE OF ISM: P   1=FOOD

                 2=SHELTER

                 3=CLOTHING/ISM TO ONE

                 4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

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

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



VERSION 1

MSSICS                           ISM                           PAGE 2 OF LISM

                                 [1-D]                      [2-O]

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

                  SHELTER EXPENSE TYPE

[15-O]                                   [16-O]

RENT FREE HOUSING:  9999999              PROPERTY TAXES:           9999999

[17-O]                                   [18-O]

MORTGAGE/RENT:      9999999              ELECTRICITY:              9999999

[19-O]                                   [20-O]

HEATING FUEL:       9999999              GARBAGE REMOVAL:          9999999

[21-O]                                   [22-O]

WATER:              9999999              SEWER:                    9999999

[23-O]                                   [24-O]

GAS:                9999999              RENTAL SUBSIDY:           PPPPPPP

[25-C]                                   [26-O]

PROPERTY INS:       9999999              MULTIPLE SHELTER ITEMS:   9999999

                         [27-D]

                         TOTAL EXPENSES:  SSSSSSSS

 [28-M]

MONTHLY VALUE: PPPPPPP

 [29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N):  X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

[10-O]                                                         [12-O]

ANOTHER SOURCE (Y/N): X                                        REMARKS (Y): X



VERSION 2

MSSICS                           ISM                           PAGE 2 OF LISM

                                 [1-D]                      [2-O]

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

                  SHELTER EXPENSE TYPE

[15-O]                                   [16-O]

RENT FREE HOUSING:  9999999              PROPERTY TAXES:           9999999

[17-O]                                   [18-O]

MORTGAGE/RENT:      9999999              ELECTRICITY:              9999999

[19-O]                                   [20-O]

HEATING FUEL:       9999999              GARBAGE REMOVAL:          9999999

[21-O]                                   [22-O]

WATER:              9999999              SEWER:                    9999999

[23-O]                                   [24-O]

GAS:                9999999              RENTAL SUBSIDY:           PPPPPPP

[25-O]                                   [26-O]

PROPERTY INS:       9999999              MULTIPLE SHELTER ITEMS:   9999999

                         [27-D]

                         TOTAL EXPENSES:  SSSSSSSS

 [28-M]

MONTHLY VALUE: PPPPPPP

 [29-C]

ARE PAYMENTS FROM ABSENT PARENT (Y/N):  X

[30-D]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

[10-O]                                                         [12-O]

ANOTHER SOURCE (Y/N): X                                        REMARKS (Y): X



VERSION 3

MSSICS                            ISM                          PAGE 2 OF LISM

                                 [1-D]                      [2-O]

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

 [28-M]

MONTHLY VALUE: PPPPPPP

[29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N):  X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

[10-O]                                                         [12-O]

ANOTHER SOURCE (Y/N): X                                        REMARKS (Y): X



VERSION 4

MSSICS                            ISM                          PAGE 2 OF LISM

                                 [1-D]                      [2-O]

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

 [28-M]

MONTHLY VALUE: PPPPPPP

 [29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N):  X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS:  SSSSSSS

[10-O]                                                         [12-O]

ANOTHER SOURCE (Y/N): X                                        REMARKS (Y): X


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