TN 5 (04-90)
This form requests information as to the living arrangements of the claimant, cash
and in kind income from all sources (including contributons from the NH) and information
to establish whether the NH had the capacity to make the contributions alleged.
The 12-month period ends with the point at which the one-half support requirement
must be met.
All questions asked on the form and any supplemental statements made in the remarks
section or on a separate SSA-795, refer to this period.
Complete all items on the form indicating “none” or “not applicable” where appropriate.
Show actual amounts when possible.
It is enough if claimant states that the NH supplied food, lodging, clothing and other
Obtain actual figures.
Obtain the date of the NH's first contributions from the claimant and record under
Develop circumstances fully. OS 15010.370