TN 15 (02-90)
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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)
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(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
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(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
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(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
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(9)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
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(10)
Choice 1- ,
Choice 2 - and
Choice 3 - .
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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)
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(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
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(4)
Choices under paragraph 1163 (4).
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(5)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
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(6)
Choice 1 - ,
Choice 2 - and
Choice 3 - Null
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(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
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(8)
Choices under paragraph 1163 (4).
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(9)
Choice 1 - for (Month/Year)
Choice 3 - for (Month/Year) on
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(10)
Choice 1 - ,
Choice 2 - and
Choice 3 - .
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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.
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(1)
Choice 1 - you
Choice 2 - she
Choice 3 - he
-
(2)
Choice 1 - you are
Choice 2 - she is
Choice 3 - he is
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(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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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.
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(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
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(2)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(3)
Choice 1 - you qualify
Choice 2 - she qualifies
Choice 3 - he qualifies
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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)
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(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
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(2)
Choice 1 - are
Choice 2 - is
Choice 3 - were
Choice 4 - was
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(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
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(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
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(5)
Choice 1 - State of (State name)
Choice 2 - District of Columbia
Choice 3 - Null
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(6)
Choice 1 - for (Month/Year)
Choice 2 - for (Month/Year) through (Month/Year)
Choice 3 - for (Month/Year) on
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(7)
Choice 1 - , in the
Choice 2 - and in the
Choice 3 - .
Choice 4 - ,
Choice 5 - and
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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.
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(1)
Choice 1 - State of (State name)
Choice 2 - District of Columbia
Choice 3 - Null
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(2)
Choice 1 - you
Choice 2 - (Name of Recipient)
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(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
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(5)
Choice 1 - you later decide you wish
Choice 2 - she later decides she wishes
Choice 3 - he later decides he wishes
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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
-
-
(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
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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
-
-
(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
-
(5)
Choice 1 - you
Choice 2 - her
Choice 3 - him
-
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
-
-
(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.
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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
-
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
-
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
-
-
(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
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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
-
-
(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
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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
-
-
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
-
-
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
-
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
-
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
-
-
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
-
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
-
-
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
-
-
(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 - .
-
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
-
-
(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
-
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
-
-
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.
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(1)
Choice 1 - you
Choice 2 - her
Choice 3 - him
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(2)
Choice 1 - State of
Choice 2 - District of Columbia
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-
(4)
Choice 1 - you later decide you wish
Choice 2 - she later decides she wishes
Choice 3 - he later decides he wishes
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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.
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(1)
Choice 1 - change was
Choice 2 - changes were
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(2)
Choice 1 - you were
Choice 2 - she was
Choice 3 - he was
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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.
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(1)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(2)
Choice 1 - monthly payment
Choice 2 - eligibility
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(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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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.
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(1)
Choice 1 - you receive
Choice 2 - she receives
Choice 3 - he receives
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(2)
Choice 1 - you
Choice 2 - she
Choice 3 - he
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(3)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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(4)
Choice 1 - your
Choice 2 - her
Choice 3 - his
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Recipient loses eligibility for a State supplementary payment.
(1) (2) not eligible for money (3) (4) (5)
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(1)
Choice 1 - You
Choice 2 - She
Choice 3 - He
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(2)
Choice 1 - are
Choice 2 - is
Choice 3 - were
Choice 4 - was
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(3)
Choice 1 - from your State
Choice 2 - from her State
Choice 3 - from his State
Choice 4 - from the District of Columbia
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(4)
Choice 1 - for (Month/Day/Year
Choice 2 - for (Month/Day/Year) through (Month/Day/Year)
Choice 3 - for (Month/Day/Year) on
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(5)
Choice 1 - ,
Choice 2 - and
Choice 3 - .