TN 5 (04-90)

RS 01301.150 Completion of Form SSA-760-F4 (Certificate of Support)


This form requests information as to the living arrangements of the claimant, cash and in kind income from all sources (including contributons from the NH) and information to establish whether the NH had the capacity to make the contributions alleged.


The 12-month period ends with the point at which the one-half support requirement must be met.

All questions asked on the form and any supplemental statements made in the remarks section or on a separate SSA-795, refer to this period.


1. General

Complete all items on the form indicating “none” or “not applicable” where appropriate.

Show actual amounts when possible.

2. Claimant Cannot Accurately Estimate NH's Contributions

a. Claimant has no income from other sources

It is enough if claimant states that the NH supplied food, lodging, clothing and other expenses.

b. Claimant had other income

Obtain actual figures.

3. NH Assumed Support During 12-Month Period

Obtain the date of the NH's first contributions from the claimant and record under “Remarks”.

4. Completion of SSA-760-F4 Reveals a Change in Support Picture During 12-Month Period

Develop circumstances fully. OS 15010.370

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RS 01301.150 - Completion of Form SSA-760-F4 (Certificate of Support) - 11/04/2015
Batch run: 11/04/2015