Application for Supplemental Security Income MSSICS

Application for Supplemental Security Income

SSA-8001 Screenshots

Application for Supplemental Security Income MSSICS

OMB: 0960-0444

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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

[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

[12-O]

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

                                                      [17-O]

                                                      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

                                                          [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

                                                              [8-O]

                                                              REMARKS (Y): X


ACLD - ADDITIONAL CLIENT DATA.



MSSICS           ADDITIONAL CLIENT DATA                    ACLD

                                                     [1-O]

SSS-SS-SSSS    SSSSS SSSSSSSSSS                      TRANSFER TO: XXXX

[2-D]

SS/SS/SSSS

[3-M]                           

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

[4-C]                          

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

[5-O]                                  

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

[10-O]

SSNS FOR APPLICABLE INELIGIBLE CHILDREN:

     BBBBBBBBB  BBBBBBBBB  BBBBBBBBB  BBBBBBBBB  BBBBBBBBB

     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

                                                     [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: VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV

[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

                                                        [11-O]

                                                        REMARKS (Y): X


ACIT – CITIZENSHIP (Deferred Application only)



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

                                                             [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

                                                          [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

[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

                      99999999                   99999999

                                                              [11-O]

                                                              REMARKS (Y): X

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

[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

[12-O]

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

 

                                                       [17-O]

                                                       REMARKS

AFIP – FINANCIAL INSTITUTIONS PERMISSION (Deferred Application only)



 MSSICS               FINANCIAL INSTITUTIONS PERMISSION               AFIP

                                                             [1-o]

  SSS-SS-SSSS  SSSSS SSSSSSSSSS                              TRANSFER TO: XXXX

 

  [2-M]

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

     [3-C]

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

  [4-M]

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

  [5-C]

  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

[2-M]

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

                                                          [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

  [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

                                                               [11-O]

                                                               REMARKS (Y): X

AMAR - MARRIAGE DATA (page 1)



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

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

 [2-M]

 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

  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

[3-M]

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):

                                                       [17-O]

                                                       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

                                                            [17-O]

                                                            REMARKS (Y): X

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

[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    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

[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    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

[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]

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

[5-M]

(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

[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]

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

[5-M]

(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

[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]

10=SSSSSS SSSSS SSSS SSSS

11=SSSSSS SSSSS SSSS SSSS

12=SSSSSS SSSSS SSSS SSSS

[5-M]

(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

[1-D]

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:

[5-M]

(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)

[1-D]

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:

[5-M]

(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

                                                   [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

MSSICS                    INCOME MENU            PAGE 2 OF IMEN

                                                   [1-O]

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

                                                   [1-O]

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

                                                   [1-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS                       TRANSFER TO:XXXX

 (Y/N) ADDITIONAL DEVELOPMENT:

      [4-O]

  X   PASS INPUT NEEDED

      [5-O]

  X   SCHOOL INPUT NEEDED

      [6-O]

  X   BLIND COUNTABLE INCOME INPUT NEEDED

      [7-O]

  X   DISPLAY INCOME SUMMARY SCREEN

[8-M]                     [3-D]

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

[9-D]

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

[8-M]                     [3-D]

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:

[9-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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)

[5-O]

(Y/N)

  X      CR WANTS TO DO FULL DEVELOPMENT

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



[9-D]

10=(NAME RELATION SSSS)

11=(NAME RELATION SSSS)

12=(NAME RELATION SSSS)

[10-O]

(Y/N)

  X      CR WANTS TO DO FULL DEVELOPMENT

         10:      11:     12:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:

[8-M]                     [3-D]

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:

[9-D]

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:





[9-D]

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:

     [11-O]

  X   PASS INPUT NEEDED

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

     [5-O]

  X   SCHOOL INPUT NEEDED

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

     [10-O]

  X   BLIND COUNTABLE INCOME INPUT NEEDED

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

     [12-O]

  X   DISPLAY INCOME SUMMARY SCREEN

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

[9-D]

01=(NAME RELATION SSSS)

02=(NAME RELATION SSSS)

03=(NAME RELATION SSSS)

 (Y/N) ADDITIONAL DEVELOPMENT:

     [11-O]

  X   PASS INPUT NEEDED

      10:  11:  12:

     [5-O]

  X   SCHOOL INPUT NEEDED

      10:  11:  12:

     [6-O] 

  X   BLIND COUNTABLE INCOME INPUT NEEDED

      10:  11:  12:

     [12-O]

  X   DISPLAY INCOME SUMMARY SCREEN

      10:  11:  12:

BMEN - POTENTIAL ELIGIBILITY FOR OTHER BENEFITS MENU



MSSICS           POTENTIAL ELIGIBILITY FOR OTHER BENEFITS MENU          BMEN

                                                            [1-O]

SSS-SS-SSSS   SSSSS SSSSSSSSSS                              TRANSFER TO: XXXX

SELECT

 (Y/N)

   [2-M]

   P   COMPLETE FOOD STAMPS QUESTIONS

   [3-M]

   X   COMPLETE HEALTH EXPENSES QUESTIONS

 [4-C]

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

                                                             [1-O]

  SSS-SS-SSSS  SSSSS SSSSSSSSSS                              TRANSFER TO: XXXX

  [2-D]

  POTENTIAL ENTITLEMENT ON SSN SSS-SS-SSSS

  [3-M]

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

  [4-C]

  SELECT REASON NOT ENTITLED: 9   1=NEVER WORKED

                                  2=NO WORK SINCE PRIOR DENIAL

                                  3=REFUSED TO FILE

  [5-C]

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

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

 

 

 

 

                                                                 [6-O]

                                                                 REMARKS (Y): X


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