HI 03094.401 Resource Worksheet
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 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.
Choice 1: your
Choice 2: your and your spouse’s
month and year of application using format “January 2006”
(date can be no earlier than January 2006)