Basic (05-05)

HI 03094.401 Resource Worksheet

A. Purpose/Use

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.

B. Sample Resource Worksheet



                                   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.




NOTE: Use the following paragraph only when we have applied the $1500 burial exclusion.



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







  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)


To Link to this section - Use this URL:
HI 03094.401 - Resource Worksheet - 05/24/2005
Batch run: 07/08/2013