Application for Supplemental Security Income MSSICS/Signature Proxy

ACID - CLIENT IDENTIFICATION
MSSICS

CLIENT IDENTIFICATION
ACID
[1-O]
TRANSFER TO: XXXX

SSS-SS-SSSS
[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
[1-O]
SSSSS SSSSSSSSSS

ACLM

SSS-SS-SSSS
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
[1-O]
SSSSS SSSSSSSSSS

PAGE 1 OF ADDR

SSS-SS-SSSS
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
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXX
[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]
permission status change (y): x

[7-C]
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
[1-O]

ALEF

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
SSSSSSSSS

RESOURCES MENU
PAGE 1 OF RMEN
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
TO

HAVE ANY OF THE LISTED PEOPLE RECEIVED AND EXPECT TO CONTINUE

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
X
X
X

OTHER INCOME BASED ON NEED
10:
11: 12:
BLACK LUNG
10:
11: 12:
RAILROAD BOARD BENEFITS
10:
11: 12:
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