Document
Application for Supplemental Security Income (SSI)
ICR 201604-0960-009 · OMB 0960-0229 · Object 63817501.
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Document Metadata
| File Type | application/msword |
|---|---|
| File Title | Application for Supplemental Security Income (SSI) |
| Author | DB |
| Last Modified By | Writer |
| File Modified | 2011-04-12 |
| File Created | 2026-08-24 |
| Conversion State | complete |
Extracted Text
MSSICS SSI MENU MSSI [1-D] FIELD OFFICE: SSS [2-C] SSN: 999999999 [3-M] SELECT: 9 1. ESTABLISH 2. UPDATE 3. QUERY [4-M] SELECT THE DESIRED FUNCTION: 99 1. ARCHIVAL RETRIEVAL 11. DELETE INELIGIBLES 2. TICKLE LIST REQUEST 12. MANUAL PROCESSES 3. NEW CLAIM 13. (FUTURE USE) 4. CLAIM UPDATE/INQUIRY 14. DECISION INPUT 5. CLAIM DEVELOPMENT 15. AUTOMATED COMPUTATIONS 6. CLAIMS CLEARANCE 16. NEW CLAIM/ABBREVIATED 7. CASE MOVEMENT 17. POSTELIGIBILITY 8. WMS QUERY REQUEST 18. DENIED CLAIM REOPENING 9. APPEALS 19. DIRECT SSR UPDATE 10. SSN CORRECTION 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 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 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 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 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 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 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 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 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 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.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 FACSIMILE: 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 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 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 FACSIMILE 1: 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 2: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE 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 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 FACSIMILE 3: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE 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 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 FACSIMILE 4: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE _ 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] 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 FACSIMILE 5: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE _ 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] 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 FACSIMILE 6: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE _ 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] 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 FACSIMILE 7: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE 1 OF RMEN SSSSSSSSS SSSSS SSSSSSSSS [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) FACSIMILE 8: RMEN - RESOURCES MENU MSSICS RESOURCES MENU PAGE 2 OF RMEN SSSSSSSSS SSSSS SSSSSSSSS [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 FACSIMILE 1: 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 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 FACSIMILE 3: IMEN - INCOME MENU 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 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 FACSIMILE 5: IMEN - INCOME MENU (MULTIPLES) MSSICS INCOME MENU PAGE _ OF IMEN [1-0] TRANSFER TO: XXXX [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: FACSIMILE 6: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-0] TRANSFER TO: XXXX [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: FACSIMILE 7: IMEN - INCOME MENU MSSICS PUBLIC MAINTENANCE/TITLE IV-D QUESTIONS PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 8: IMEN - INCOME MENU MSSICS PUBLIC MAINTENANCE/TITLE IV-D QUESTIONS PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 9: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 10: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 11: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 12: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 13: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 14: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 15: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 16: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 17: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: FACSIMILE 18: IMEN - INCOME MENU MSSICS INCOME MENU PAGE _ OF IMEN [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [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: 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. 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 MSSICS CDW SSI MENU DWME [1-O] SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX [2-O] SHOW (Y) DATA GROUP NAME X PRINT OPTIONS X APPEAL PRINT OPTIONS X DEVELOPMENT WORKSHEET x attestation X DISABILITY TRANSMITTAL X PERSON STATEMENT X PERSON STATEMENT LIST X REPORT OF CONTACT X REPORT OF CONTACT LIST X DEVELOPMENT DOCUMENTATION X DEVELOPMENT DOCUMENTATION LIST X paper indicator X REQUEST ALL