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