The Resource Worksheet is a listing of the applicant’s resources, the value of each resource, and the total countable resources. It is generated as an attachment to the following subsidy notices: Award, Denial, Pre-Decisional, Change, Planned Action, Termination, and Redetermination-SSA Initiated. A Resource Worksheet is not generated if the applicant has no resources. The Resource Worksheet is generated by MAPS.

 

 

                                   SOCIAL SECURITY ADMINISTRATION

 

                  How We Counted __1__Resources To Determine Your Subsidy

                                             For __2__ and continuing

 

 

 

Bank Accounts                                                                                         $___1___

 

Stocks, Bonds, or Other Investments                                                          ___2___

 

Cash                                                                                                           ___3___

 

Cash Value of Life Insurance                                                                       ___4___

 

Real Property                                                                                             ___5___

 

(Burial Fund Money We Do Not Count)                                                     (___6___)

 

 

Your Resources That We Count                                                            $___7___

 

 

Resource Limit for Subsidy Eligibility                                                $___8___

 

  

Amount Over The Resource Limit                                                       $___9___

 

 

 

We counted only the resources listed above. We do not count the value of your home,

your vehicles or your personal possessions.

 

 

 

 

 

Because you have set aside money for burial expenses, we also do not count $1,500.

 

 

 

 

Fill-in’s

 

1. 1) 

   Choice 1: your

   Choice 2: your and your spouse’s

2. 2) 

   month and year of application using format “January 2006”

   (date can be no earlier than January 2006)