SI SF01210.527 Livermore Questionnaire

The following questions pertain to all months since the last review of SSI eligibility:

  1. Have you changed your State of residence from California at any time since we last reviewed your case?

    • Yes _______ No ________

    • If yes, when did you change your State of residence? _______________

  2. Have you married at any time since we last reviewed your case,

    • Yes _______ No ________

    • If yes, what is your spouse’s name and social security number?

  3. If yes to question 2, has your spouse ever received SSI or payments under a State aid plan (AB, ATD, OAS, or AFDC/TANF?

    • Yes ________ No ________

    • If no:

      • (a) Have you had any minor children living with you and your spouse at any time since we last reviewed your case?

        Yes ________ No ________

        If yes, list the names, dates of birth, and income (if any) of the children:

      • (b) Do you pay for any medical needs of your children or spouse?

        Yes ________ No ________

        If yes” what are your children’s and spouse’s medical needs:

        _____________________________ $ ____________________

      • (c) Did your spouse incur any debts to provide family needs before you received assistance:

        Yes ________ No ________

        If yes, how much? $ ______________

      • (d) Did your spouse pay for such things as major house repair or replacement of furniture?

        Yes ________ No ________

        If yes, how much? $ ______________

  4. Have you worked or engaged in self-employment at any time since we last reviewed your case?

    Yes ________ No ________

    Has your spouse?

    Yes ________ No ________

    If yes, what are your (your spouse’s) work expenses?

       Taxes, retirement $ ____________

       Transportation    $ ____________

       Insurance             $ ____________

       Meals             $ ____________

       Child care         $ ____________

       Other             $ ____________

  5. Do you live in your own home, apartment, etc.? Yes _______ No _______

    If yes:

    How much is the rent or mortgage? ____________

    Do others live with you? Yes ________ No ________

    How many people are in the household? ___________

  6. Do you live with someone and pay them for room and board? Yes ____ No ____

    If yes, how much do you pay per month? $ _________

  7. Do you live in a nonmedical board and care facility? Yes ______ No _______

  8. Do you live in a medical facility or intermediate care facility? Yes ____ No ____

  9. Does anyone else pay any of the following expenses for you?

    Food         Yes ____ No ____

    Clothing     Yes ____ No ____

    Rent         Yes ____ No ____

    Transportation Yes ____ No ____

    Utilities     Yes ____ No ____

  10. Did you receive a nonrecurring lump sum payment such as a title II, worker’s compensation, or pension payment? Yes _______ No _______

    If yes, when? ____________

    How much $ ____________

  11. Did you receive a tax refund? Yes _______ No _______

    If yes, when? Yes _______ No _______

    How much? ______________

  12. Do you pay someone to provide domestic or personal care services in your own home? Yes _______ No _______

    If yes, how much? $ _____________


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0501210527SF
SI SF01210.527 - Livermore Questionnaire - 01/29/2018
Batch run: 01/29/2018
Rev:01/29/2018