TN 15 (02-90)

NL 00804.190 State Involvement

  1. Situation Where Used:

IC: Award—State living arrangement category—State supplement payable.

PE: Individual or individual living with eligible spouse, ineligible spouse or essential person changes living arrangement. Optional supplement is federally administered. (Individual is in current pay status.)

 

For purposes of the money we pay    (1)    for    (2)    State    (3)          (4)          (5)          (6)          (7)          (8)           (9)          (10)   

 

  1. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

    Choice 4 - you and your spouse are

    Choice 5 - she and her spouse are

    Choice 6 - he and his spouse are

    Choice 7 - you were

    Choice 8 - she was

    Choice 9 - he was

    Choice 10 - you and your spouse were

    Choice 11 - she and her spouse were

    Choice 12 - he and his spouse were

     

  4. Choice 1 - living independently

    Choice 2 - living independently with cooking facilities

    Choice 3 - living independently without cooking facilities

    Choice 4 - living in the household of another

    Choice 5 - living with others

    Choice 6 - living with one or two persons

    Choice 7 - living with three or more persons

    Choice 8 - living with a dependent person

    Choice 9 - living with an ineligible spouse

    Choice 10 - living alone or purchasing room and board

    Choice 11 - living in the household of another with an ineligible spouse

    Choice 12 - in domiciliary care

    Choice 13 - in domiciliary care level I

    Choice 14 - in domiciliary care level II

    Choice 15 - in domiciliary care level III

    Choice 16 - in an adult foster care home

    Choice 17 - in a family life home approved by the State

    Choice 18 - in an adult foster care and boarding home

    Choice 19 - in a home for the aged

    Choice 20 - in a private nonmedical group home

    Choice 21 - in licensed custodial care

    Choice 22 - in unlicensed custodial care

    Choice 23 - in congregate care level I

    Choice 24 - in congregate care level II

    Choice 25 - in congregate care level III

    Choice 26 - in a licensed boarding home for sheltered care

    Choice 27 - in a licensed developmentally disabled home level II

    Choice 30 - in a licensed developmentally disabled home level III

    Choice 31 - in a licensed developmentally disabled home level IV

    Choice 32 - in a licensed developmentally disabled home level V

    Choice 33 - in a foster care or licensed boarding home with five or fewer beds

    Choice 34 - in a foster care or licensed boarding home with more than five beds

    Choice 35 - receiving personal care

    Choice 36 - receiving nonmedical board and care

    Choice 37 - receiving adult residential care

    Choice 36 - receiving supervised licensed custodial care

    Choice 37 - sharing living expenses

    Choice 38 - a disabled minor in the household of a parent or relative

    Choice 39 - in adult foster care—50 or less beds

    Choice 40 - in adult foster care—over 50 beds

    Choice 41 - living independently with an essential person

    Choice 42 - living in the household of another with an essential person

    Choice 43 - living independently with a non-spouse essential person

    Choice 44 - living in the household of another with a non-spouse essential person

    Choice 45 - living independently with an ineligible spouse who is an essential person

    Choice 46 - living in the household of another with an ineligible spouse who is an essential person

    Choice 47 - living alone or with others

    Choice 48 - living in a residential care facility

    Choice 49 - living in a group home for the mentally disabled

    Choice 50 - living in a community home for the developmentally disabled

    Choice 51 - living in a foster care home

    Choice 52 - living in a semi-independent care facility

    Choice 53 - in a licensed foster home

    Choice 54 - in a licensed boarding home

    Choice 55 - in a cost-reimbursement home

    Choice 56 - in a hospital or other institution and more than half the cost of the care is provided by Medicaid

    Choice 57 - Null

     

  5. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

     

  6. Choice 1 - ,

    Choice 2 - and

    Choice 3 - Null

     

  7. Choice 1 - and your spouse is

    Choice 2 - and her spouse is

    Choice 3 - and his spouse is

    Choice 4 - and your spouse was

    Choice 5 - and her spouse was

    Choice 6 - and his spouse was

    Choice 7 - Null

     

  8. Choice 1 - living independently

    Choice 2 - living independently with cooking facilities

    Choice 3 - living independently without cooking facilities

    Choice 4 - living in the household of another

    Choice 5 - living with others

    Choice 6 - living with one or two persons

    Choice 7 - living with three or more persons

    Choice 8 - living with a dependent person

    Choice 9 - living with an ineligible spouse

    Choice 10 - living alone or purchasing room and board

    Choice 11 - living in the household of another with an ineligible spouse

    Choice 12 - in domiciliary care

    Choice 13 - in domiciliary care level I

    Choice 14 - in domiciliary care level II

    Choice 15 - in domiciliary care level III

    Choice 16 - in an adult foster care home

    Choice 17 - in a family life home approved by State

    Choice 18 - in an adult foster care and boarding home

    Choice 19 - in a home for the aged

    Choice 20 - in a private nonmedical group home

    Choice 21 - in licensed custodial care

    Choice 22 - in unlicensed custodial care

    Choice 23 - in congregate care level I

    Choice 24 - in congregate care level II

    Choice 25 - in congregate care level III

    Choice 26 - in a licensed boarding home for sheltered care

    Choice 27 - in a licensed developmentally disabled home level II

    Choice 28 - in a licensed developmentally disabled home level III

    Choice 29 - in a licensed developmentally disabled home level IV

    Choice 30 - in a licensed developmentally disabled home level V

    Choice 31 - in a foster care or licensed boarding home with five or fewer beds

    Choice 32 - in a foster care or licensed boarding home with more than five beds

    Choice 33 - receiving personal care

    Choice 34 - receiving nonmedical board and care

    Choice 35 - receiving adult residential care

    Choice 36 - receiving supervised licensed custodial care

    Choice 37 - sharing living expenses

    Choice 38 - a disabled minor in the household of a parent or relative

    Choice 39 - in adult foster care—50 or less beds

    Choice 40 - in adult foster care—over 50 beds

    Choice 41 - living independently with an essential person

    Choice 42 - living in the household of another with an essential person

    Choice 43 - living independently with a non-spouse essential person

    Choice 44 - living in the household of another with a non-spouse essential person

    Choice 45 - living independently with an ineligible spouse who is an essential person

    Choice 46 - living in the household of another with an ineligible spouse who is an essential person

    Choice 47 - living alone or with others

    Choice 48 - living in a residential care facility

    Choice 49 - living in a group home for the mentally disabled

    Choice 50 - living in a community home for the developmentally disabled

    Choice 51 - living in a foster care home

    Choice 52 - living in a semi-independent care facility

    Choice 53 - in a licensed foster home

    Choice 54 - in a licensed boarding home

    Choice 55 - in a cost-reimbursement home

    Choice 56 - in a hospital or other institution and more than half the cost of the care is provided by Medicaid

    Choice 57 - Null

     

  9. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

     

  10. Choice 1- ,

    Choice 2 - and

    Choice 3 - .

     

  1. Situation Where Used:

IC: Award—State living arrangement category—no State supplement payable.

PE: Individual or individual living with eligible spouse, ineligible spouse or essential person changes living arrangement. Optional supplement is federally administered. (Individual is not in current pay status.)

 

For purposes of determining    (1)    eligibility for payments from    (2)    State,    (3)          (4)          (5)          (6)          (7)           (8)          (9)          (10)   

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you are

    Choice 2 - you and your spouse are

    Choice 3 - she is

    Choice 4 - she and her spouse are

    Choice 5 - he is

    Choice 6 - he and his spouse are

    Choice 7 - you were

    Choice 8 - you and your spouse were

    Choice 9 - she was

    Choice 10 - she and her spouse were

    Choice 11 - he was

    Choice 12 - he and his spouse were

     

  4. Choices under paragraph 1163 (4).

     

  5. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

     

  6. Choice 1 - ,

    Choice 2 - and

    Choice 3 - Null

     

  7. Choice 1 - and your spouse is

    Choice 2 - and her spouse is

    Choice 3 - and his apouse is

    Choice 4 - and your spouse was

    Choice 5 - and her spouse was

    Choice 6 - and his spouse was

     

  8. Choices under paragraph 1163 (4).

     

  9. Choice 1 - for (Month/Year)

    Choice 3 - for (Month/Year) on

     

  10. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

  1. Situation Where Used:

Denial of State supplement payments.

 

The application    (1)    filed is also an application for additional State payments under the Supplemental Security Income program. For reasons shown above,    (2)    not eligible for such payments from    (3)    State.

 

  1. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  2. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  1. Situation Where Used:

IC: Referral to State agency—State administers supplementation program.

PE: Recipient moves to a State that also administers its own supplementation program.

 

   (1)    may want to contact    (2)    local public assistance office to find out if    (3)    for payments from them.

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you qualify

    Choice 2 - she qualifies

    Choice 3 - he qualifies

     

  1. Situation Where Used:

IC: State and county of residence during initial period of eligibility.

PE: Individual and/or spouse changes State (and/or county, if applicable) of residence. SSA administers State supplement. (This paragraph is used only if residence change causes a payment change.)

 

   (1)          (2)    living in the    (3)          (4)          (5)          (6)           (7)   

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

    Choice 4 - You and your spouse

    Choice 5 - She and her spouse

    Choice 6 - He and his spouse

    Choice 7 - Your spouse

    Choice 8 - Her spouse

    Choice 9 - His spouse

     

  2. Choice 1 - are

    Choice 2 - is

    Choice 3 - were

    Choice 4 - was

     

  3. Choice 1 - county of Albany in the

    Choice 2 - county of Allegany in the

    Choice 3 - county of Bronx in the

    Choice 4 - county of Broome in the

    Choice 5 - county of Cattarugus in the

    Choice 6 - county of Cayuga in the

    Choice 7 - county of Chautauqua in the

    Choice 8 - county of Chemung in the

    Choice 9 - county of Chenango in the

    Choice 10 - county of Clinton in the

    Choice 11 - county of Columbia in the

    Choice 12 - county of Courtland in the

    Choice 13 - county of Delaware in the

    Choice 14 - county of Dutchess in the

    Choice 15 - county of Erie in the

    Choice 16 - county of Essex in the

    Choice 17 - county of Franklin in the

    Choice 18 - county of Fulton in the

    Choice 19 - county of Genesee in the

    Choice 20 - county of Greene in the

    Choice 21 - county of Hamilton in the

    Choice 22 - county of Herkimer in the

    Choice 23 - county of Jefferson in the

    Choice 24 - county of Kings in the

    Choice 25 - county of Lewis in the

    Choice 26 - county of Livingston in the

    Choice 27 - county of Madison in the

    Choice 28 - county of Monroe in the

    Choice 29 - county of Montgomery in the

    Choice 30 - county of Nassau in the

    Choice 31 - county of New York in the

    Choice 32 - county of Niagara in the

    Choice 33 - county of Oneida in the

    Choice 34 - county of Onondago in the

    Choice 35 - county of Ontario in the

    Choice 36 - county of Orange in the

    Choice 37 - county of Orleans in the

    Choice 38 - county of Oswego in the

    Choice 39 - county of Otsego in the

    Choice 40 - county of Putnam in the

    Choice 41 - county of Queens in the

    Choice 42 - county of Rensselaer in the

    Choice 43 - county of Richmond in the

    Choice 44 - county of Rockland in the

    Choice 45 - county of St. Lawrence in the

    Choice 46 - county of Saratoga in the

    Choice 47 - county of Schenectady in the

    Choice 48 - county of Schoharie in the

    Choice 49 - county of Schuyler in the

    Choice 50 - county of Seneca in the

    Choice 51 - county of Steuben in the

    Choice 52 - county of Suffolk in the

    Choice 53 - county of Sullivan in the

    Choice 54 - county of Tioga in the

    Choice 55 - county of Tompkins in the

    Choice 56 - county of Ulster in the

    Choice 57 - county of Warren in the

    Choice 58 - county of Washington in the

    Choice 59 - county of Wayne in the

    Choice 60 - county of Westchester in the

    Choice 61 - county of Wyoming in the

    Choice 62 - county of Yates in the

    Choice 63 - Null

     

  4. Choice 1 - county of Adams in the

    Choice 2 - county of Asotin in the

    Choice 3 - county of Benton in the

    Choice 4 - county of Chelan in the

    Choice 5 - county of Clallam in the

    Choice 6 - county of Clark in the

    Choice 7 - county of Columbia in the

    Choice 8 - county of Cowlitz in the

    Choice 9 - county of Douglas in the

    Choice 10 - county of Ferry in the

    Choice 11 - county of Franklin in the

    Choice 12 - county of Garfield in the

    Choice 13 - county of Grant in the

    Choice 14 - county of Grays Harbor in the

    Choice 15 - county of Island in the

    Choice 16 - county of Jefferson in the

    Choice 17 - county of King in the

    Choice 18 - county of Kitsap in the

    Choice 19 - county of Kittitas in the

    Choice 20 - county of Klickitat in the

    Choice 21 - county of Lewis in the

    Choice 22 - county of Lincoln in the

    Choice 23 - county of Mason in the

    Choice 24 - county of Okanogan in the

    Choice 25 - county of Pacific in the

    Choice 26 - county of Pend Oreille in the

    Choice 27 - county of Pierce in the

    Choice 28 - county of San Juan in the

    Choice 29 - county of Skagit in the

    Choice 30 - county of Skamania in the

    Choice 31 - county of Snohomish in the

    Choice 32 - county of Spokane in the

    Choice 33 - county of Stevens in the

    Choice 34 - county of Thurston in the

    Choice 35 - county of Wahkiakum in the

    Choice 36 - county of Walla Walla in the

    Choice 37 - county of Whatcom in the

    Choice 38 - county of Whitman in the

    Choice 39 - county of Yakima in the

    Choice 40 - Null

     

  5. Choice 1 - State of (State name)

    Choice 2 - District of Columbia

    Choice 3 - Null

     

  6. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

     

  7. Choice 1 - , in the

    Choice 2 - and in the

    Choice 3 - .

    Choice 4 - ,

    Choice 5 - and

     

  1. Situation Where Used:

Individual waives State supplement.

 

The Social Security Administration administers a State supplement in the    (1)    for which    (2)    may qualify. Based on     (3)    request, we will not send you any money from    (4)    . If    (5)    to receive this money, you should contact any Social Security office.

 

  1. Choice 1 - State of (State name)

    Choice 2 - District of Columbia

    Choice 3 - Null

     

  2. Choice 1 - you

    Choice 2 - (Name of Recipient)

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your State

    Choice 2 - the District of Columbia

    Choice 3 - the State

     

  5. Choice 1 - you later decide you wish

    Choice 2 - she later decides she wishes

    Choice 3 - he later decides he wishes

     

  1. Situation Where Used:

Recipient moves from one State with federally administered State supplementation to another. State supplement due.

 

   (1)    moved out of the    (2)    . Therefore, beginning    (3)          (4)    no longer eligible for payment from that State. However,    (5)    due State money from the    (6)    as shown above.

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. (Month/Year)

     

  4. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  5. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  6. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  1. Situation Where Used

Recipient moves from a State which has no supplementation program or administers its own State supplementation program to a State which has a federally administered supplementation program. State supplement payable.

 

   (1)    due State money as a resident of the    (2)    beginning    (3)    . In figuring the amount of    (4)    check, we have included the State money due    (5)    .

 

  1. Choice 1 - You are

    Choice 2 - She is

    Choice 3 - He is

     

  2. Choice 1 - State of            

    Choice 2 - District of Columbia

     

  3. (Month/Year)

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  1. Situation Where Used:

Recipient moves from a State in which he/she receives a federally administered State supplement to a State which has no supplementation program. Recipient is in current pay status (for Federal payment only).

 

   (1)    moved out of the    (2)    . Therefore, beginning    (3)    ,    (4)    no longer eligible for payment from that State.    (5)   

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - State of            

    Choice 2 - District of Columbia

     

  3. (Month/Year)

     

  4. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  5. Choice 1 - You are now due money from the United States Government only.

    Choice 2 - She is now due money from the United States Government only.

    Choice 3 - He is now due money from the United States Government only.

     

  1. Situation Where Used:

Recipient was receiving Federally administered State supplement. The State has decided to administer its own suplementation program.

 

NOTE: This paragraph has never been active on the SSR.

 

The check we have been sending    (1)    included money from the    (2)    .    (3)    will continue to receive the    (4)    check from the Social Security Administration. The money from    (5)    will no longer be included in the check we sent you.    (6)    will send    (7)    a separate monthly check for any money due    (8)    from the    (9)    .

 

  1. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  4. Choice 1 - SSI

    Choice 2 - Null

     

  5. Choice 1 - your State

    Choice 2 - her State

    Choice 3 - his State

    Choice 4 - the District of Columbia

     

  6. Choice 1 - Your State

    Choice 2 - Her State

    Choice 3 - His State

    Choice 4 - The District of Columbia

     

  7. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  8. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  9. Choice 1 - State

    Choice 2 - District of Columbia

     

  1. Situation Where Used:

Recipient (who is ineligible for a Federal payment) has been receiving federally administered State supplement. The State has decided to administer its own supplementation program.

 

NOTE: This paragraph has never been active on the SSR.

 

The check we have been sending you was for money due    (1)    from the    (2)    .    (3)    will now send you a check each month for any money due    (4)    . This will take the place of the    (5)    check we have been sending you.

 

  1. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. Choice 1 - Your State

    Choice 2 - Her State

    Choice 3 - His State

    Choice 4 - The District of Columbia

     

  4. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  5. Choice 1 - SSI

    Choice 2 - Null

     

  1. Situation Where Used:

Recipient has been receiving Federal payments as well as State administered supplement. The State has switched to federally administered supplementation program.

 

NOTE: This paragraph has never been active on the SSR.

 

   (1)    been receiving a monthly check from the    (2)    .    (3)    has asked us to include this payment in     (4)    check beginning    (5)    . The    (6)    check you receive includes money due    (7)    .

 

  1. Choice 1 - You have

    Choice 2 - She has

    Choice 3 - He has

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. Choice 1 - Your State

    Choice 2 - Her State

    Choice 3 - His State

    Choice 4 - The District of Columbia

     

  4. Choice 1 - your SSI

    Choice 2 - her SSI

    Choice 3 - his SSI

     

  5. (Month/Year)

     

  6. Choice 1 - SSI

    Choice 2 - Null

     

  7. Choice 1 - you from your State

    Choice 2 - her from her State

    Choice 3 - him from his State

    Choice 4 - you from the District of Columbia

    Choice 5 - her from the District of Columbia

    Choice 6 - him from the District of Columbia

     

  1. Situation Where Used:

Recipient (who is ineligible for Federal payments) has been receiving State administered supplement. The State has switched to a federally administered supplementation program.

 

NOTE: This paragraph has never been active on the SSR.

 

   (1)    been receiving a monthly check from the    (2)    .    (3)    has asked us to send    (4)    this payment beginning    (5)    . The    (6)    check you receive is the money due    (7)    .

 

  1. Choice 1 - You have

    Choice 2 - She has

    Choice 3 - He has

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. Choice 1 - Your State

    Choice 2 - Her State

    Choice 3 - His State

    Choice 4 - The District of Columbia

     

  4. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  5. (Month/Year)

     

  6. Choice 1 - SSI

    Choice 2 - Null

     

  7. Choice 1 - you from your State

    Choice 2 - her from her State

    Choice 3 - him from his State

    Choice 4 - you from the District of Columbia

    Choice 5 - her from the District of Columbia

    Choice 6 - him from the District of Columbia

     

  1. Situation Where Used:

Recipient is receiving federally administered State supplement. Change in State supplement amount due to change in law, regulations, policy, or rates payable.

 

Because of a change in the amount    (1)    State has asked us to pay,    (2)    State payment has been    (3)    beginning    (4)    .

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - you, your

    Choice 2 - her, her

    Choice 3 - him, his

     

  3. Choice 1 - increased

    Choice 2 - reduced

    Choice 3 - stopped

     

  4. (Month/Year)

     

  1. Situation Where Used:

Special need reduction reported.

 

   (1)    a special payment for    (2)    special need beginning    (3)    .

 

  1. Choice 1 - You no longer need

    Choice 2 - She no longer needs

    Choice 3 - He no longer needs

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. (Month/Year)

     

  1. Situation Where Used:

Recipient was erroneously converted and payments or eligibility is being terminated.

 

We have    (1)    based on information that    (2)    eligible for and received State assistance payments for the aged, blind, or disabled for December 1973.

 

Our records now show that    (3)    not eligible to receive a State payment for December 1973.    (4)    under Federal rules was also considered. However, the evidence shows    (5)    not eligible within the meaning of the law.

 

Therefore,    (6)    in the past. If at any time you feel that    (7)    for the SSI program, you should call or visit     (8)     local Social Security office to file an application for the Supplemental Security Income program.

 

  1. Choice 1 - been paying you Supplemental Security Income

    Choice 2 - been paying her Supplemental Security Income

    Choice 3 - been paying him Supplemental Security Income

    Choice 4 - you eligible under the Supplemental Security Income program

    Choice 5 - her eligible under the Supplemental Security Income program

    Choice 6 - him eligible under the Supplemental Security Income program

     

  2. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  3. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  4. Choice 1 - Your eligibility for payments

    Choice 2 - Her eligibility for payments

    Choice 3 - His eligibility for payments

    Choice 4 - Your eligibility for the Supplemental Security Income program.

    Choice 5 - Her eligibility for the Supplemental Security Income program

    Choice 6 - His eligibility for the Supplemental Security Income program

     

  5. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  6. Choice 1 - you should not have received payments

    Choice 2 - she should not have received payments

    Choice 3 - he should not have received payments

    Choice 4 - you should not have been eligible

    Choice 5 - she should not have been eligible

    Choice 6 - he should not have been eligible

     

  7. Choice 1 - you qualify

    Choice 2 - she qualifies

    Choice 3 - he qualifies

     

  8. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  1. Situation Where Used:

December 1973 grant amount changed.

 

NOTE: Used with paragraphs 2335, and 2336 or 2337.

 

In December 1973,    (1)    eligible for a State assistance payment from the    (2)    .

 

  1. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  2. Choice 1 - State of            

    Choice 2 - District of Columbia

     

  1. Situation Where Used:

December 1973 grant amount changed.

 

NOTE: Used with paragraphs 2335, and 2336 or 2337.

 

The amount of aid or assistance    (1)    should have received from the    (2)    for December 1973 is    (3)    .

 

  1. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  2. Choice 1 - State of            

    Choice 2 - District of Columbia

     

  3. $$$.¢¢

     

  1. Situation Where Used:

December 1973 Federal arrangement changed.

 

NOTE: Used with paragraphs 2335, and 2336 or 2337.

 

In December 1973,    (1)    living in    (2)    .

 

  1. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  2. Choice 1 - your own household

    Choice 2 - her own household

    Choice 3 - his own household

    Choice 4 - the household of your parents

    Choice 5 - the household of her parents

    Choice 6 - the household of his parents

    Choice 7 - the household of someone else

    Choice 8 - a hospital or other institution and more than half the cost of your care was provided by Medicaid

    Choice 9 - a hospital or other institution and more than half the cost of her care was provided by Medicaid

    Choice 10 - a hospital or other institution and more than half the cost of his care was provided by Medicaid

     

  1. Situation Where Used:

December 1973 countable income changed.

 

NOTE: Used with paragraphs 2335, and 2336 or 2337.

 

The amount of    (1)    income for December 1973, which is counted under Federal rules, is    (2)    .

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. $$$.¢¢

     

  1. Situation Where Used:

State countable income (Vermont) changed.

 

NOTE: Used with paragraphs 2335, and 2336 or 2337.

 

For purposes of determining the amount of State money    (1)    eligible for,    (2)    income under the rules of Vermont is     (3)          (4)          (5)   

 

  1. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. $$$.¢¢

     

  4. Choice 1 - for (Month/Year)

    Choice 2 - for (Month/Year) through (Month/Year)

    Choice 3 - for (Month/Year) on

     

  5. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

  1. Situation Where Used:

State countable income (Vermont) changed. Recipient not currently Vermont resident and was not a Vermont resident during any of the period covered by the income change.

 

   (1)    income under the rules of Vermont is    (2)          (3)          (4)    this determination may affect the amount of    (5)    payment if    (6)    back to Vermont.

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

  2. $$$.¢¢

     

  3. Choice 1 - for (Month/Day/Year)

    Choice 2 - for (Month/Day/Year) through Month/Day/Year)

    Choice 3 - for (Month/Day/Year) on

     

  4. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - you move

    Choice 2 - she moves

    Choice 3 - he moves

     

  1. Situation Where Used:

Recipient (who is eligible for Federal payments) moves from a State in which he /she is not eligible for a State supplement to another State in which he /she is not eligible for a State supplement.

 

NOTE: This paragraph has never been active on the SSR.

 

   (1)    moved into the    (2)    in    (3)    .

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - State of       

    Choice 2 - District of Columbia

     

  3. (Month/Year)

     

  1. Situation Where Used:

Individual resides in a State for which SSA administers its optional supplementation program. Individual waives supplementation.

 

Based on your request, we will no longer send    (1)    money from the    (2)    beginning    (3)    . If    (4)    to receive this money, you should contact any Social Security office.

 

  1. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  2. Choice 1 - State of            

    Choice 2 - District of Columbia

     

  3. (Month/Day/Year)

     

  4. Choice 1 - you later decide you wish

    Choice 2 - she later decides she wishes

    Choice 3 - he later decides he wishes

     

  1. Situation Where Used:

Change of State of conversion, 1973 Federal living arrangement, December 1973 countable income. State (Vermont) countable income, or special need reduction reported.

 

The above    (1)    made because our records show    (2)    eligible for and received a State assistance payment for December 1973, immediately before the Federal Supplemental Security Income program began.

 

  1. Choice 1 - change was

    Choice 2 - changes were

     

  2. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  1. Situation Where Used:

Change in State of conversion, December 1973 grant amount, December 1973 Federal living arrangement, December 1973 countable income, State (Vermont) countable income, or special need reduction reported.

 

Even though there is no change in    (1)          (2)    as a result of this determination, the amount of    (3)    future payments may be affected if    (4)    circumstances change.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - monthly payment

    Choice 2 - eligibility

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  1. Situation Where Used:

Change in State of conversion, December 1973 grant amount, December 1973 Federal living arrangement, December 1973 countable income, State (Vermont) countable income, or special need reduction reported.

 

Because of this    (1)    a higher payment than    (2)    otherwise would. But we have to refigure    (3)    monthly payment when some change is reported to us that would have affected     (4)    State payment in December 1973. This is what we have now done.

 

  1. Choice 1 - you receive

    Choice 2 - she receives

    Choice 3 - he receives

     

  2. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  1. Situation Where Used:

Recipient loses eligibility for a State supplementary payment.

 

   (1)