Ask the person(s) making the statement whether they have received any public income maintenance (PIM) payments in the past, including the period from the first moment of the filing month, or expects to receive any this month or in the next 14 months. (PIM payments are listed in 1(b) on the form.)

NOTE: Do not list as State and local income maintenance assistance those items which specifically do not meet the definition of income, such as social services (see SI 00810.010), or assistance excluded by other Federal statutes.

1. a. 

   Complete 1(b) if question 1(a) is answered “Yes.”

2. b. 

   If the person's share of a family assistance grant (e.g., AFDC) is unknown, show the total family grant under “AMOUNT.”

3. c. 

   Go to question 2.

If question 1(a) is answered "No," go to question 3.