The following questions pertain to all months since the last review of SSI eligibility:
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1.
Have you changed your State of residence from California at any time since we last
reviewed your case?
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If yes, when did you change your State of residence? _______________
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2.
Have you married at any time since we last reviewed your case,
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If yes, what is your spouse’s name and social security number?
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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?
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If no:
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(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:
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(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:
_____________________________ $ ____________________
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(c) Did your spouse incur any debts to provide family needs before you received assistance:
Yes ________ No ________
If yes, how much? $ ______________
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(d) Did your spouse pay for such things as major house repair or replacement of furniture?
Yes ________ No ________
If yes, how much? $ ______________
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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 $ ____________
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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? ___________
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6.
Do you live with someone and pay them for room and board? Yes ____ No ____
If yes, how much do you pay per month? $ _________
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7.
Do you live in a nonmedical board and care facility? Yes ______ No _______
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8.
Do you live in a medical facility or intermediate care facility? Yes ____ No ____
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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 ____
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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 $ ____________
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11.
Did you receive a tax refund? Yes _______ No _______
If yes, when? Yes _______ No _______
How much? ______________
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12.
Do you pay someone to provide domestic or personal care services in your own home?
Yes _______ No _______
If yes, how much? $ _____________