Form SSA-8000-BK, Application for Supplemental Security Income (SSI) Instructions

Check this box if you (the applicant) own, or your name appears on, an ABLE account.

Check this box if you (the applicant) do not own and your name does not appear on any ABLE account.

Check this box if your spouse owns, or their name appears on, an ABLE account. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any ABLE account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own or have cash at home, with you, or anywhere else.

Check this box if you (the applicant) do not own or have any cash at home, with you, or anywhere else.

Check this box if your spouse owns or has cash at home, with them, or anywhere else. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own or have any cash at home, with them, or anywhere else. Fill only if 'Are you married?' is 'Yes'.

Check this box if you own, or your name appears on (either alone or with any other person's name), any checking account.

Check this box if you do not own and your name does not appear on any checking account.

Check this box if your spouse owns, or your spouse's name appears on (either alone or with any other person's name), any checking account. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and your spouse's name does not appear on any checking account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you personally own, or your name appears on, a Christmas Club account (either alone or with another person).

Check this box if you do not own and your name does not appear on a Christmas Club account.

Check this box if your spouse personally owns, or their name appears on, a Christmas Club account (either alone or with another person). Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on a Christmas Club account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own or your name appears on a credit union account.

Check this box if you (the applicant) do not own and your name does not appear on a credit union account.

Check this box if your spouse owns or their name appears on a credit union account. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on a credit union account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you own, or your name appears on (either alone or with any other person's name), any financial institution accounts.

Check this box if you do not own and your name does not appear on any financial institution accounts.

Check this box if your spouse owns, or your spouse's name appears on (either alone or with any other person's name), any financial institution accounts. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and your spouse's name does not appear on any financial institution accounts. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the claimant) own, or your name appears on, an Individual Indian Money Account.

Check this box if you (the claimant) do not own and your name does not appear on an Individual Indian Money Account.

Check this box if your spouse owns, or your spouse's name appears on, an Individual Indian Money Account. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and your spouse's name does not appear on an Individual Indian Money Account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own or your name appears on any 'Other (Including IRAs and Keough Accounts)' account (including IRAs or Keough accounts).

Check this box if you (the applicant) do not own and your name does not appear on any 'Other (Including IRAs and Keough Accounts)' account (including IRAs or Keough accounts).

Check this box if your spouse owns or your spouse's name appears on any 'Other (Including IRAs and Keough Accounts)' account (including IRAs or Keough accounts). Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and your spouse's name does not appear on any 'Other (Including IRAs and Keough Accounts)' account (including IRAs or Keough accounts). Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own, or your name appears on (alone or jointly), a savings account.

Check this box if you (the applicant) do not own and your name does not appear on any savings account.

Check this box if your spouse owns, or their name appears on (alone or jointly), a savings account. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any savings account. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own or your name appears on any time deposits or certificates of deposit.

Check this box if you (the applicant) do not own and your name does not appear on any time deposits or certificates of deposit.

Check this box if your spouse owns or their name appears on any time deposits or certificates of deposit. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any time deposits or certificates of deposit. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the person who owns the financial item listed on this row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name or short description of the financial item (for example, checking account, savings, IRA, etc.). Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the current value of the item. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the full name and mailing address of the bank or other organization that holds or issued the item. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the account, policy, or other identifying number associated with this item (include any letters, dashes, or other characters as shown). Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name of the person who owns the financial item shown on the fourth row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name or brief description of the financial item listed on the fourth row (for example, 'Checking Account' or 'Individual Retirement Account'). Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the dollar value of the financial item on the fourth row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the full name and mailing address of the bank or other organization that holds or issued the financial item on the fourth row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the account, policy, or other identifying number associated with the financial item on the fourth row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the full name of the owner of the asset or account being reported on the second row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Provide the specific name or brief description of the financial item (for example, checking account, IRA, time deposit) for the second row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the dollar value of the item being reported on this row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name and mailing address of the bank or other organization that holds or issued the item listed on the second row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the account, policy, or other identifying number associated with the item shown on this row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name of the person who owns the financial item reported on this row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the name or brief description of the financial item being reported (for example, checking account, IRA, or certificate of deposit). Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the total value of the item reported on this row. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the full name and mailing address of the bank or other organization that holds or manages the reported item. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Enter the account, policy, or other identifying number associated with the reported item. Fill only if '41(a) Cash at home - You: YES', '41(a) Cash at home - Your Spouse: YES', '41(a) You — Financial Institution Accounts: Yes', '41(a) Your Spouse — Financial Institution Accounts: Yes', '41(a) You - Achieving a Better Life Experience (ABLE) - YES', '41(a) Your Spouse - Achieving a Better Life Experience (ABLE) - YES', '41(a) Checking — You (YES)', '41(a) Checking — Your Spouse (YES)', '41(a) Savings — You: YES', '41(a) Savings — Your Spouse: YES', '41(a) Credit Union — You: Yes', '41(a) Credit Union — Your Spouse: Yes', '41(a) You — YES (Christmas Club)', '41(a) Your Spouse — YES (Christmas Club)', '41(a) Time Deposits/Certificates of Deposit — You: YES', '41(a) Time Deposits/Certificates of Deposit — Your Spouse: YES', '41(a) Individual Indian Money Account - You: YES', '41(a) Individual Indian Money Account - Your Spouse: YES', '41(a) Other (Including IRAs and Keough Accounts) — You: YES', '41(a) Other (Including IRAs and Keough Accounts) — Your Spouse: YES' is 'Yes' (any).

Check this box if you give permission for the agency to obtain any financial records from any financial institution.

Check this box if you do not give permission for the agency to obtain any financial records from any financial institution.

Check this box if your spouse (if filing) gives permission for the agency to obtain any financial records from any financial institution. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse (if filing) does not give permission for the agency to obtain any financial records from any financial institution. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if you (your name alone or with another person) own any bonds, including U.S. Savings Bonds.

Check this box if you do not own and your name does not appear on any bonds, including U.S. Savings Bonds.

Check this box if your spouse (their name alone or with another person) owns any bonds, including U.S. Savings Bonds. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any bonds, including U.S. Savings Bonds. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own, or your name appears on, any items that can be turned into cash.

Check this box if you (the applicant) do not own and your name does not appear on any items that can be turned into cash.

Check this box if your spouse owns, or their name appears on, any items that can be turned into cash. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any items that can be turned into cash. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the claimant) own or your name appears on any promissory notes.

Check this box if you (the claimant) do not own and your name does not appear on any promissory notes.

Check this box if your spouse owns or their name appears on any promissory notes. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any promissory notes. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) own, or your name appears on, any stocks or mutual funds.

Check this box if you (the applicant) do not own and your name does not appear on any stocks or mutual funds.

Check this box if your spouse owns, or their name appears on, any stocks or mutual funds. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own and their name does not appear on any stocks or mutual funds. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does own cemetery lots, crypts, caskets, vaults, urns, mausoleums, other repositories for burial, or any headstones or markers. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse does not own any cemetery lots, crypts, caskets, vaults, urns, mausoleums, other repositories for burial, or any headstones or markers. Fill only if 'Are you married?' is 'Yes'.

Check this box if you personally own any cemetery lots, crypts, caskets, vaults, urns, mausoleums, other repositories for burial, or any headstones or markers.

Check this box if you personally do not own any cemetery lots, crypts, caskets, vaults, urns, mausoleums, other repositories for burial, or any headstones or markers.

Enter the full name of the person or entity that owns the cemetery lot, crypt, casket, vault, urn, mausoleum, or marker listed on this row. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Provide a brief description of the cemetery property on this row (for example lot location, lot number, crypt or vault details, or type of marker). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the name of the person for whose burial the cemetery property is intended or reserved as shown on this row. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

State your (or your spouse’s) relationship to the person named in the 'For Whose Burial' field for this row (for example: self, spouse, parent, child). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the current market value of the cemetery property listed on this row. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the full name of the owner of the cemetery lot, crypt, casket, vault, urn, mausoleum, or marker listed on row 2. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Provide a brief description of the cemetery property on row 2 (for example: lot number, location, type of marker, or other identifying details). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the full name of the person for whom this cemetery property is intended or used, as listed on row 2. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

State your relationship to the person named for burial on row 2 (for example: self, spouse, parent, child, other). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Provide the current market value of the cemetery property listed on row 2. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the full name of the owner of this cemetery lot, crypt, casket, vault, mausoleum, or marker for this row. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Provide a brief description or identifying details of the cemetery property (such as lot location, section, type of memorial, or other distinguishing information). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the name of the person for whom the space or item is reserved or intended for burial. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

State the relationship of the person named for burial to you or your spouse (for example: self, spouse, parent, child, other). Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Enter the current market value of this cemetery property. Fill only if '47(a) You - YES', '47(a) Your Spouse - YES' is 'Yes' for any fields selection.

Check this box if you have sold, transferred title, disposed of, or given away any money or other property (including property in foreign countries) since the first moment of the filing date month or within the 36 months prior to the filing date month.

Check this box if you have NOT sold, transferred title, disposed of, or given away any money or other property in that time period.

Check this box if your spouse has sold, transferred title, disposed of, or given away any money or other property (including property in foreign countries) since the first moment of the filing date month or within the 36 months prior to the filing date month. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has NOT sold, transferred title, disposed of, or given away any money or other property in that time period. Fill only if 'Are you married?' is 'Yes'.

Check if, within the 36 months prior to the filing date month, you sold, transferred title to, disposed of, or gave away any co-owned money or property.

Check if you did not sell, transfer, dispose of, or give away any co-owned money or property within the 36 months prior to the filing date month.

Check if, within the 36 months prior to the filing date month, your spouse sold, transferred title to, disposed of, or gave away any co-owned money or property. Fill only if 'Are you married?' is 'Yes'.

Check if your spouse did not sell, transfer, dispose of, or give away any co-owned money or property within the 36 months prior to the filing date month. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the owner or co-owner who sold, transferred, disposed of, or gave away the property. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Provide a brief description of the property that was disposed (for example, vehicle, household goods, bank account, etc.). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the date when the property was sold, transferred, given away, or otherwise disposed. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the full name and mailing address of the person or entity that purchased or received the property. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Describe the relationship of the purchaser or recipient to the owner (for example, friend, son, business associate, unrelated buyer). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the value of the property transferred or the amount of any cash gift associated with this item. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the sales price or other consideration received for the property, if any. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Explain whether any additional consideration or future proceeds are expected from this disposition and provide relevant details. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you still own any part of the property described as Item 1 (i.e., you retained ownership after the disposal). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you do not still own any part of the property described as Item 1 (i.e., you no longer own the property). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was not sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was given away (transferred as a gift) rather than sold or traded. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was not given away as a gift. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was exchanged or traded for goods or services. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item 1 property was not traded for goods or services. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the full name of the owner or co-owner associated with the property disposed of in Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Provide a brief description of the property that was sold, transferred, gifted, or otherwise disposed of for Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the date on which the property listed in Item 2 was disposed of. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Provide the name and mailing address of the purchaser or recipient who received the property in Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

State the relationship of the purchaser or recipient to the owner (for example, friend, relative, business buyer) for Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the monetary value of the property or the amount of any cash gift associated with Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the sales price or other consideration received for the property listed in Item 2. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Explain whether any other consideration or proceeds are expected related to the property in Item 2 and provide details. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you still own part of the property listed for Item #2 at the time of filing. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you do not own any part of the property listed for Item #2 (the property was fully disposed of). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was not sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was given away (transferred without payment). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was not given away. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was traded or bartered for goods or services instead of sold for cash. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the Item #2 property was not traded for goods or services. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the full name of the owner or co‑owner who disposed of the property for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Provide a brief description of the property that was sold, transferred, given away, or otherwise disposed of for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the date when the property was disposed for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Provide the full name and mailing address of the purchaser or recipient who received the property for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Describe the relationship (if any) between the purchaser/recipient and the owner for Item 3 (for example, friend, relative, business associate). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the monetary value of the property or the amount of any cash gift given for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the sales price or other monetary consideration received in exchange for the property for Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Describe any other consideration or expected proceeds related to the disposal of the property for Item 3 and explain the details. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you still own part of the property described in Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if you do not still own any part of the property described in Item 3. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was not sold on the open market. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was given away (transferred without payment). Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was not given away. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was traded in exchange for goods or services. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Check this box if the property listed as Item 3 was not traded for goods or services. Fill only if '48(a) You - YES', '48(a) Your Spouse - YES', '48(b) You — YES', '48(b) Your Spouse — YES' is 'Yes' for any fields selection.

Enter the full name of the person who receives this income.

Describe the type or source of income (for example, wages, pension, rental income, benefits).

Enter the amount received for this income source.

Indicate how often the payment is made (for example, weekly, monthly, annually, one-time).

Enter the date the payment is expected or was received.

Provide the name and mailing address of the person, bank, organization, or company that is the source of the income.

Enter any identifying number associated with the source (such as an account number, employer ID, or other reference number).

Enter the full name of the person who receives the second listed income.

Describe the kind of income for this second entry (for example, wages, pension, Social Security, child support).

Enter the amount of money received for this income in the reporting period for the second entry.

Enter how often this income is paid for the second entry (for example, weekly, monthly, or annually).

Provide the date the payment is expected or was received for this income (second entry).

Provide the name and mailing address of the person, bank, organization, or company that is the source of this income (second entry).

Enter any account number, claim number, or other identifying number associated with this income source for the second entry.

Enter the full name of the person who receives the income for this entry.

Enter the kind of income received (for example, wages, pension, SSI, unemployment, etc.).

Enter the monetary amount of income received for this entry.

Enter how often the income is paid (for example, weekly, biweekly, monthly, or annually).

Enter the date the income is expected to be paid or the date it was received.

Enter the name and address of the person, bank, organization, or company that provides the income.

Enter the account, policy, or other identifying number associated with the income source (for example, an account or claim number).

Check this box if you are currently married.

Check this box if you are not currently married.

Enter the date the marriage occurred. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Enter your spouse's full legal name in the order: first name, middle initial (if any), and last name. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Enter your spouse's date of birth. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Enter your spouse's Social Security Number as shown on their Social Security card, including all digits. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Check this box if your spouse ever used any other names (including a maiden name) or used any other Social Security numbers; if checked, continue to item (e). Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Check this box if your spouse has never used any other names (including a maiden name) and has not used any other Social Security numbers; if checked, skip to item (f). Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Enter any other names your spouse has used (including maiden name, former names, or aliases); list each name clearly (one per line or separated by commas). Fill only if '5(d) YES — Spouse used other names or Social Security Numbers' Fill only if Did your spouse ever use any other names (including maiden name) or Social Security Numbers? is 'Yes'.

Enter any other Social Security Numbers your spouse has used, listing each full number clearly (separate multiple numbers with commas). Fill only if '5(d) YES — Spouse used other names or Social Security Numbers' Fill only if Did your spouse ever use any other names (including maiden name) or Social Security Numbers? is 'Yes'.

Check this box if you and your spouse are currently living together. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Check this box if you and your spouse are not currently living together. Fill only if '5(a) YES — Are you married?' Fill only if Are you married? is 'Yes'.

Enter the date you began living apart from your spouse. Fill only if '5(f) Living together (you and spouse) — NO' Fill only if Are you and your spouse living together? is 'No'.

Enter the spouse's full mailing address or the full name and contact information of someone who knows where the spouse is (provide street, city, state, ZIP and phone if available); complete this only if spouse is age 65, blind, or disabled.

Check this box if any overpayments are being collected from benefits you receive (if checked, explain in Remarks, then go to #51).

Check this box if no overpayments are being collected from benefits you receive (if checked, go to #51).

Check this box if overpayments are being collected from any benefits your spouse receives (Social Security, Railroad Retirement, OPM, VA, military, workers' comp, state disability/unemployment, etc.).

Check this box if no overpayments are being collected from any benefits your spouse receives.

Check this box if, since the first moment of the filing date month, you have received or expect to receive any meals or other gifts which are not cash; if checked, explain in Remarks and then go to #52.

Check this box if, since the first moment of the filing date month, you have not received and do not expect to receive any meals or other gifts which are not cash; if checked, go to #52.

Check this box if your spouse has received or expects to receive any meals or other gifts that are not cash since the first moment of the filing date month; also explain in Remarks and then go to #52.

Check this box if your spouse has not received and does not expect to receive any meals or other gifts that are not cash since the first moment of the filing date month; then go to #52.

Check this box if you (the applicant) have received wages or sick pay since the first moment of the filing date month through the current month.

Check this box if you (the applicant) have not received and do not expect to receive wages or sick pay since the first moment of the filing date month through the current month.

Check this box if your spouse has received wages or sick pay since the first moment of the filing date month through the current month.

Check this box if your spouse has not received any wages or sick pay since the first moment of the filing date month through the current month.

Enter the employer's full name, street address (including city, state, and ZIP) and telephone number with area code if known for your current or most recent employer. Fill only if '52(a) You - YES' is 'Yes'.

Enter your spouse's employer full name and complete mailing address, including telephone number and area code if known. Fill only if '52(a) Your Spouse - YES' is 'Yes'.

Enter the date when you last performed work during the filing month. Fill only if '52(a) You - YES' is 'Yes'.

Enter the date when you last received pay for work or sick pay during the filing month. Fill only if '52(a) You - YES' is 'Yes'.

Enter the date when you expect to be next paid for work or sick pay during the filing month. Fill only if '52(a) You - YES' is 'Yes'.

Enter the calendar date your spouse last performed work for pay. Fill only if '52(a) Your Spouse - YES' is 'Yes'.

Enter the calendar date your spouse last received a payment from that employment. Fill only if '52(a) Your Spouse - YES' is 'Yes'.

Enter the calendar date your spouse is next scheduled to receive pay from that employment. Fill only if '52(a) Your Spouse - YES' is 'Yes'.

Enter the total monthly wages you received before any deductions for the filing month. Fill only if '52(a) You - YES' is 'Yes'.

Enter the total monthly wages your spouse received before any deductions for the filing month. Fill only if '52(a) Your Spouse - YES' is 'Yes'.

Check this box if you expect to receive any wages in the next 14 months (if checked, continue to item (f)).

Check this box if you do not expect to receive any wages in the next 14 months (if checked, go to #53).

Check this box if your spouse expects to receive any wages in the next 14 months (if checked, continue to item (f)).

Check this box if your spouse does not expect to receive any wages in the next 14 months (if checked, go to #53).

Check this box if you (the applicant) agree to assign your rights (or the rights of anyone for whom you can legally assign rights) to payments for medical support and other medical care to the State Medicaid agency (then go to (b)).

Check this box if you (the applicant) do not agree to assign those rights to the State Medicaid agency (if you select No, follow the form instruction to go to #59).

Check this box if your spouse (if filing) agrees to assign their rights (or the rights of anyone they can legally assign) to payments for medical support and other medical care to the State Medicaid agency (then go to (b)). Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse (if filing) does not agree to assign those rights to the State Medicaid agency (if your spouse selects No, follow the form instruction to go to #59). Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if you (the applicant) have private, group, or governmental health insurance (not Medicare or Medicaid) that pays the cost of your medical care.

Check this box if you (the applicant) do not have private, group, or governmental health insurance (excluding Medicare or Medicaid) that pays the cost of your medical care.

Check this box if your spouse (if filing) has private, group, or governmental health insurance (not Medicare or Medicaid) that pays the cost of their medical care. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse (if filing) does not have private, group, or governmental health insurance (excluding Medicare or Medicaid) that pays the cost of their medical care. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if you (the applicant) had any unpaid medical expenses for the three months prior to the filing date month.

Check this box if you (the applicant) did not have any unpaid medical expenses for the three months prior to the filing date month.

Check this box if your spouse (if filing) had any unpaid medical expenses for the three months prior to the filing date month. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse (if filing) did not have any unpaid medical expenses for the three months prior to the filing date month. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if you have ever worked under the U.S. Social Security System.

Check this box if you have never worked under the U.S. Social Security System.

Check this box if you (the applicant) have worked for an employer that provided a pension plan.

Check this box if you (the applicant) have not worked for an employer that provided a pension plan.

Check this box if your spouse or parent has worked for an employer that provided a pension plan.

Check this box if your spouse or parent has not worked for an employer that provided a pension plan.

Check this box if a claim for benefits has been filed for the person (the 'Filed for Benefits' column) based on work for an employer that provided a pension plan.

Check this box if no claim for benefits has been filed for the person (the 'Filed for Benefits' column) based on work for an employer that provided a pension plan.

Check this box if you (the applicant) have worked for a railroad.

Check this box if you (the applicant) have not worked for a railroad.

Check this box if your spouse or parent has worked for a railroad.

Check this box if your spouse or parent has not worked for a railroad.

Check this box if benefits have been filed for railroad work for the person in this column.

Check this box if no benefits have been filed for railroad work for the person in this column.

Check this box if you (the applicant/you) HAVE worked for a state or local government.

Check this box if you (the applicant/you) have NOT worked for a state or local government.

Check this box if your spouse or parent (if you are filing as a child) HAS worked for a state or local government.

Check this box if your spouse or parent (if you are filing as a child) has NOT worked for a state or local government.

Check this box if the person for whom benefits are being filed HAS worked for a state or local government.

Check this box if the person for whom benefits are being filed has NOT worked for a state or local government.

Check this box if you (the applicant) have been in military service.

Check this box if you (the applicant) have not been in military service.

Check this box if your spouse (or your parent, if you are filing as a child) has been in military service.

Check this box if your spouse (or your parent, if you are filing as a child) has not been in military service.

Check this box if the person for whom benefits are being filed has been in military service.

Check this box if the person for whom benefits are being filed has not been in military service.

Check this box if you (the applicant) have worked under a Social Security system or pension plan of a country other than the United States.

Check this box if you (the applicant) have NOT worked under a Social Security system or pension plan of a country other than the United States.

Check this box if your spouse or parent has worked under a Social Security system or pension plan of a country other than the United States.

Check this box if your spouse or parent has NOT worked under a Social Security system or pension plan of a country other than the United States.

Check this box if benefits or a claim have been filed under the non‑U.S. Social Security system or pension plan referenced.

Check this box if benefits or a claim have NOT been filed under the non‑U.S. Social Security system or pension plan referenced.

Check this box if you have belonged to a union that provided a pension plan.

Check this box if you have not belonged to a union that provided a pension plan.

Check this box if your spouse or parent (the person for whom you are filing) has belonged to a union that provided a pension plan.

Check this box if your spouse or parent (the person for whom you are filing) has not belonged to a union that provided a pension plan.

Check this box if a benefits claim has been filed for the person and that person belonged to a union that provided a pension plan.

Check this box if a benefits claim has been filed for the person and that person did not belong to a union that provided a pension plan.

Check this box if you (the applicant) have worked for the Federal Government.

Check this box if you (the applicant) have not worked for the Federal Government.

Check this box if your spouse or parent has worked for the Federal Government.

Check this box if your spouse or parent has not worked for the Federal Government.

Check this box if the person for whom benefits are being filed has worked for the Federal Government.

Check this box if the person for whom benefits are being filed has not worked for the Federal Government.

Provide a clear explanation and the applicable dates for any "Yes" answers given in question #14 or #59(a) that apply to your spouse or parent (if filing as a child), including what happened and the start and end dates for each item. Fill only if '59(a) YES — Worked under U.S. Social Security System' is 'Yes' (any 'Yes' answer requiring explanation in 59(c)).

Provide a clear explanation and the relevant dates for any "Yes" answers you gave in question #14 or #59(a), including what happened, your role or relationship, and the start and end dates (or ongoing status) for each item. Fill only if '59(a) YES — Worked under U.S. Social Security System' is 'Yes' (any 'Yes' answer requiring explanation in 59(c)).

Check this box if you have never been married.

Check this box if you (the applicant) have had other marriages (Yes).

Check this box if you (the applicant) have not had any other marriages (No).

Check this box if your spouse (if filing) has had other marriages (Yes).

Check this box if your spouse (if filing) has not had any other marriages (No).

Enter the full name of your former spouse, including first name, middle initial (if any), and last name or maiden name. Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Enter the birth date of your former spouse. Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Enter the Social Security Number of your former spouse exactly as issued (include any leading zeros). Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Enter the date the prior marriage began. Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Enter the date the prior marriage ended. Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Provide the reason the prior marriage ended (for example, divorce, annulment, or death). Fill only if '6(a) You - YES' Fill only if Have you had any other marriages? (You) is 'Yes'.

Enter the full name (first, middle initial, last) of the person who was previously married to your spouse, including maiden name if applicable. Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Enter the birth date of the person who was previously married to your spouse. Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Enter the Social Security number (SSN) of the person who was previously married to your spouse as it appears on their records. Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Enter the date the marriage to your spouse's former spouse took place. Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Enter the date the marriage to your spouse's former spouse ended. Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Provide how the marriage ended (for example, divorce, annulment, death, or separation). Fill only if '6(a) Your Spouse - YES' Fill only if Have you had any other marriages? (Your Spouse, if filing) is 'Yes'.

Check this box if you and another person are living together and presenting yourselves to others or the community as a married couple (holding out); if checked, also provide the date this holding out began.

Enter the date when you and the other person began living together and presenting yourselves to others or the community as a married couple. Fill only if '6(c) YES — Holding out as married' Fill only if Are you and another person living together in the same household and presenting to others or the community as a married couple? is 'Yes'.

Check this box if you and another person are not living together and presenting yourselves as a married couple (i.e., you are not holding out as married).

Enter the other person's full name (first, middle initial, and last) as requested for item 6(d). Fill only if '6(c) YES — Holding out as married' Fill only if Are you and another person living together in the same household and presenting to others or the community as a married couple? is 'Yes'.

Enter the other person's Social Security Number exactly as issued, without spaces or dashes. Fill only if '6(c) YES — Holding out as married' Fill only if Are you and another person living together in the same household and presenting to others or the community as a married couple? is 'Yes'.

Enter the full name of the person or agency requesting benefits on behalf of the claimant. Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Enter the requester’s relationship to the claimant (for example: parent, spouse, legal guardian, attorney, agency). Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Enter the requester’s Social Security Number or Employer Identification Number associated with the person or agency requesting benefits. Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Check this box if SSA determines the claimant needs help managing benefits and you want to be selected as the claimant's representative payee. Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Check this box if SSA determines the claimant needs help managing benefits but you do NOT want to be selected as the claimant's representative payee (explain why in Remarks). Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Check this box if you have previously served as a representative payee for a Social Security beneficiary or SSI claimant. Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Check this box if you have never served as a representative payee for a Social Security beneficiary or SSI claimant. Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents'.

Enter the applicant's full legal name including first name, middle initial (if any), and last name.

Check this box if the applicant's sex is male (mark only one sex option for the applicant).

Check this box if the applicant's sex is female (mark only one sex option for the applicant).

Enter the applicant's date of birth.

Enter the applicant's Social Security Number (SSN) exactly as issued, including any leading zeros.

Enter the applicant’s mailing address including house/building number and street name, and include apartment, unit, P.O. Box, or rural route if applicable.

Enter the city and state (for U.S. addresses) or the city and province/region (for foreign addresses) for the applicant’s mailing address.

Enter the ZIP code or postal code for the applicant’s mailing address (include ZIP+4 or extended postal code if applicable).

Enter the county for U.S. mailing addresses or the country for foreign mailing addresses.

Enter the applicant's full name as their handwritten signature (first name, middle initial, last name) to certify the accuracy of the information on the form.

Provide the date on which the applicant signed the form.

Enter the telephone number(s) where the applicant can be reached during the day.

Check this box if you or your spouse HAVE acquired any assets since the first moment of the filing date month.

Check this box if you and your spouse have NOT acquired any assets since the first moment of the filing date month.

Describe each asset you or your spouse acquired since the first moment of the filing date month, including what the asset is, date acquired, approximate value, and the name/address of the source or seller. Fill only if 'Assets Acquired Since Filing Month - YES' is 'Yes'.

Enter the city where your spouse was born. Fill only if 'Are you married?' is 'Yes'.

Enter the U.S. state or province where your spouse was born (leave blank if not applicable). Fill only if 'Are you married?' is 'Yes'.

Enter the country where your spouse was born if it is other than the United States; otherwise leave blank or write 'USA' if requested. Fill only if 'Are you married?' is 'Yes'.

Enter the city where you were born.

Enter the U.S. state or region where you were born (use the full name or standard postal abbreviation).

If you were born outside the United States, enter the name of the country of your birth; otherwise leave blank or enter 'USA' as appropriate.

Check this box if you have a felony or an outstanding arrest warrant (for example, escape from custody, flight-escape, or flight to avoid prosecution or confinement) that you must report to Social Security.

Enter a brief description of the felony or arrest warrant you must report, including the nature of the incident or reason (for example, escape, flight to avoid prosecution, or other relevant details).

Check this box if the amount of help (money or payment of household expenses) you receive goes up or down, or if someone starts or stops helping you.

Check this box if any of the 'How You Live' events occur — for example, someone moves into or out of your household; the amount you pay toward household expenses changes; a birth or death of someone you live with; your spouse or former spouse dies; or your marital status or living arrangements change (marriage, separation, divorce, annulment, or beginning to live as a married couple).

Check this box if your immigration status changes — you must report any changes in your immigration status to Social Security.

Check this box when you (or your spouse/parent) have any income-related change listed on the form — for example, you start receiving payments, have a change in the amount you receive, begin or change child support payments, start or stop work, earn more or less money, or become eligible for other benefits.

Check this box if you are the child's parent, stepparent, or representative payee and must report any of the listed changes (income, student status, marital or residence changes, or changes in value of things they own) to Social Security.

Check this box if you have been selected to act as a representative payee for an SSI recipient and must report changes for that person (including if you can no longer or no longer wish to act as their representative payee).

Check this box if the value of things you own goes over $2,000 (or $3,000 if you are married and live with your spouse), or if you sell or give away anything of value, or if you buy or are given anything of value.

Check this box if you are unmarried and under age 22 and must report changes such as starting or stopping school, getting married or divorced, or starting or stopping work.

Check this box if you are reporting a change to where you live (for example: you moved, you or your spouse left your household for a calendar month or longer, you left the United States for 30 consecutive days, or you are no longer a legal resident of the United States).

Check this box if you are blind or disabled and you need to report that your condition has improved or your doctor says you can return to work, or if you begin to go to work.

Enter the full legal name of the claimant (first, middle initial if used, and last name) for the first person.

Enter the claimant's Social Security Number for the first person exactly as issued, including any leading zeros.

Enter the date associated with this receipt for the first person (the date the form was completed or issued).

Enter the full name (first, middle initial if any, and last) of the second person making the claim.

Enter the second person's Social Security Number (nine digits) for this claim.

Enter the date associated with this second person's entry (e.g., date of signature or filing).

Enter the claimant’s full street address (house number, street name, and apartment or unit number if applicable) if it is different from the applicant’s mailing address.

Enter the city and state for U.S. addresses, or the city and province/region for a foreign residence.

Enter the ZIP code or postal code for the claimant’s residence address.

Enter the county for U.S. addresses or the country name for a foreign residence.

Enter the telephone number the applicant or representative can be reached at for questions or to report information (include area code and any extension if applicable).

Enter the name, street address, city, state and ZIP code of the Social Security office you may visit or to which you will mail requests or correspondence.

Check this box if the spouse or parent who lives with you is required to pay court-ordered support; if checked, proceed to item (b).

Check this box if the spouse or parent who lives with you is not required to pay court-ordered support; if checked, follow the form's NOTE instructions.

Enter the dollar amount of the court-ordered support payment your spouse/parent is required to pay. Fill only if '55a - YES (Spouse/parent pays court-ordered support)' is 'Yes'.

Enter how often the court-ordered support payment is made (for example, monthly, weekly, biweekly, or annually). Fill only if '55a - YES (Spouse/parent pays court-ordered support)' is 'Yes'.

Enter the full legal name of the person who receives the court-ordered support payments. Fill only if '55a - YES (Spouse/parent pays court-ordered support)' is 'Yes'.

Enter the recipient's complete mailing address (street address, apartment or unit if any, city, state, and ZIP code). Fill only if '55a - YES (Spouse/parent pays court-ordered support)' is 'Yes'.

Check this box if your current residence is a house (a standalone single-family home).

Check this box if your current residence is an apartment (a unit in a multi-unit building).

Check this box if you live in a room inside someone else's private home.

Check this box if you live in a room in a commercial lodging or establishment (for example, a boarding house, hotel, or similar).

Check this box if your current residence is a mobile home or trailer you live in.

Check this box if your current residence is a houseboat (a boat used as your home).

Check this box if your residence type is not listed above and provide the specific type in the space provided.

Enter the specific type of current residence if none of the listed options apply (for example, 'boarding house', 'shelter', 'assisted living', etc.).

Enter the bank routing transit (ABA) number for the financial institution where you want your Supplemental Security Income deposited. Fill only if 'Checking', 'Savings' is 'Yes' on any.

Enter the bank account number where you want your Supplemental Security Income deposited. Fill only if 'Checking', 'Savings' is 'Yes' on any.

Check this box if you want your SSI payments deposited into a checking account.

Check this box if you want your SSI payments deposited into a savings account.

Check this box if you want to enroll to receive your SSI payments on the Direct Express prepaid debit card instead of a bank account.

Check this box if you refuse direct deposit and do not want your SSI payments deposited into a bank account or Direct Express.

Check this box if you have received or expect to receive State Disability income since the first moment of the filing date month or within the next 14 months.

Check this box if you have not received and do not expect to receive State Disability income since the first moment of the filing date month or within the next 14 months.

Check this box if your spouse has received or expects to receive State Disability income since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive State Disability income since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if you have received or expect to receive veteran payments not based on need (paid directly or indirectly as a dependent) since the first moment of the filing month or within the next 14 months.

Check this box if you have not received and do not expect to receive veteran payments not based on need (paid directly or indirectly as a dependent) since the first moment of the filing month or within the next 14 months.

Check this box if your spouse has received or expects to receive veteran payments not based on need (paid directly or indirectly as a dependent) since the first moment of the filing month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive veteran payments not based on need (paid directly or indirectly as a dependent) since the first moment of the filing month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter your household's average monthly electricity expense for the past 12 months (or average for the months you have lived at your current address). Fill only if 'Present living situation' is 'Household'.

Check this box if you (the applicant) have received or expect to receive Black Lung benefit income in the next 14 months.

Check this box if you (the applicant) have not received and do not expect to receive Black Lung benefit income in the next 14 months.

Check this box if your spouse has received or expects to receive Black Lung benefit income in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive Black Lung benefit income in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name and mailing address of your spouse's employer, including city, state, ZIP code, and telephone number if known.

Enter the full name and mailing address of your employer (if different from item #52(b)), including the employer's telephone number if known.

Check this box if your spouse expects any change in the wage information provided in item #52(g); if checked, continue to part (i) to explain the change.

Check this box if your spouse does not expect any change in the wage information provided in item #52(g); if checked, proceed to item #53 as indicated on the form.

Check this box if you (the applicant) expect any change in the wage information you provided in item #52(g).

Check this box if you (the applicant) do not expect any change in the wage information you provided in item #52(g).

Enter the number of days after you provided all requested information that you should expect to hear from Social Security (enter the number of days).

Provide a clear, concise explanation of the change to your spouse's wage information, including what changed (amount, rate, hours, employer, or pay schedule), the reason for the change, and any relevant dates or other details needed to understand and verify the change. Fill only if 'Your Spouse - YES' is 'Yes'.

Provide a clear, concise explanation of how your wage information has changed (for example: reason for change, effective date, new pay rate or hours, and any other relevant details). Fill only if 'You — YES (Expect change in wage information)' is 'Yes'.

Check this box if you have received or expect to receive Military Special Pay or Allowance since the first moment of the filing date month or within the next 14 months.

Check this box if you have not received and do not expect to receive Military Special Pay or Allowance since the first moment of the filing date month or within the next 14 months.

Check this box if your spouse has received or expects to receive Military Special Pay or Allowance since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive Military Special Pay or Allowance since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the fifth child who is receiving income. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Describe the source and type of the fifth child’s income (for example, wages, Social Security, child support, etc.). Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Enter the monthly amount of income the fifth child receives from this source. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Check this box if, since the first moment of the filing date month, you have received or expect to receive SNAP (Supplemental Nutrition Assistance Program) income in the next 14 months.

Check this box if, since the first moment of the filing date month, you have not received and do not expect to receive SNAP (Supplemental Nutrition Assistance Program) income in the next 14 months.

Check this box if, since the first moment of the filing date month, your spouse has received or expects to receive SNAP (Supplemental Nutrition Assistance Program) income in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if, since the first moment of the filing date month, your spouse has not received and does not expect to receive SNAP (Supplemental Nutrition Assistance Program) income in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the first child who is receiving income. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Describe the source and type of income the first child receives (for example, Social Security, wages, benefits, or child support). Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Enter the monthly amount of income the first child receives. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Check this box if you have received or expect to receive state or local need-based assistance since the first moment of the filing date month or within the next 14 months.

Check this box if you have not received and do not expect to receive state or local need-based assistance since the first moment of the filing date month or within the next 14 months.

Check this box if your spouse has received or expects to receive state or local need-based assistance since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive state or local need-based assistance since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the owner for the first other property listed. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter the estimated current market value of the first other property. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter the outstanding amount owed on the first other property. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter the full name of the person listed on the vehicle title as the owner. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the vehicle's year, make, and model (for example: 2018 Honda Civic). Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the primary use of the vehicle (for example: personal, commuting, business). Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the current market value of this vehicle. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the outstanding loan or lien balance still owed on this vehicle. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Check this box if you (the applicant) have received or expect to receive pension income (foreign military, state, local, private, union, retirement, or disability) since the first moment of the filing date month or within the next 14 months.

Check this box if you (the applicant) have not received and do not expect to receive any of the listed pension income since the first moment of the filing date month or within the next 14 months.

Check this box if your spouse has received or expects to receive pension income (foreign military, state, local, private, union, retirement, or disability) since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive any of the listed pension income since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the fourth child who is receiving income. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Describe the source and type of the fourth child's income (for example, wages, Social Security, pension, benefits, or other). Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Enter the monthly amount of income the fourth child receives. Fill only if 'Q26(b) YES - Child/studente receives income' is 'Yes'.

Check this box if you have received or expect to receive General Assistance from the Bureau of Indian Affairs in the next 14 months (answer for you = YES).

Check this box if you have not received and do not expect to receive General Assistance from the Bureau of Indian Affairs in the next 14 months (answer for you = NO).

Check this box if your spouse has received or expects to receive General Assistance from the Bureau of Indian Affairs in the next 14 months (answer for spouse = YES). Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive General Assistance from the Bureau of Indian Affairs in the next 14 months (answer for spouse = NO). Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the person who owns the fourth listed property or item. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter your best estimate of the current market value of the fourth listed property or item. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter the outstanding amount owed (liens, loans, or mortgages) on the fourth listed property or item. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter the full name of the person who appears on the title for the fourth vehicle. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Provide the vehicle's year, make, and model (for example: 2018 Toyota Camry) for the fourth vehicle. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Briefly describe how the fourth vehicle is used (for example: personal, work, business, or recreational use). Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the current market value of the fourth vehicle as a numeric amount. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the outstanding loan or lien amount currently owed on the fourth vehicle as a numeric value. Fill only if 'Q39 - You: YES (Own or name appears on vehicle title)', 'Q39 - Your Spouse: YES (Spouse owns or name appears on vehicle title)' is 'Yes' (any).

Enter the average monthly amount you pay for garbage removal over the past 12 months (or the average for the months you have lived at your current address). Fill only if 'Present living situation' is 'Household'.

Provide the average monthly amount your household pays for gas (show the average over the past 12 months, or for the months you have resided at your present address if less than 12). Fill only if 'Present living situation' is 'Household'.

Enter the Social Security Administration website address shown on the form (for example, www.socialsecurity.gov).

Enter the average monthly amount you paid for heating fuel over the past 12 months, or the average for the months you have lived at your current address if less than 12 months. Fill only if 'Present living situation' is 'Household'.

Enter the full name of the fifth person who lives with you (first, middle, last).

Enter the relationship of the fifth household member to you (for example: spouse, child, parent, roommate).

Check this box if the fifth listed household member currently receives public assistance (answer YES).

Check this box if the fifth listed household member does not receive public assistance (answer NO).

Check this box if the fifth listed household member's sex is male.

Check this box if the fifth listed household member's sex is female.

Enter the birthdate of the fifth household member.

Check this box if the fifth listed household member is blind or has a disability (answer YES).

Check this box if the fifth listed household member is not blind and does not have a disability (answer NO).

If the fifth listed household member is under age 22, check this box if they are married (answer YES).

If the fifth listed household member is under age 22, check this box if they are not married (answer NO).

If the fifth listed household member is under age 22, check this box if they are currently a student (answer YES).

If the fifth listed household member is under age 22, check this box if they are not a student (answer NO).

Enter the Social Security Number for the fifth household member.

Enter the full name of the first household member who lives with you.

Enter this person’s relationship to you (for example, spouse, child, parent, roommate).

Check this box if the first household member receives public assistance.

Check this box if the first household member does not receive public assistance.

Check this box if the first household member is male.

Check this box if the first household member is female.

Enter the date of birth of this household member.

Check this box if the first household member is blind or disabled.

Check this box if the first household member is not blind and not disabled.

If the first household member is under age 22 and is married, check this box.

If the first household member is under age 22 and is not married, check this box.

If the first household member is under age 22 and is a student, check this box.

If the first household member is under age 22 and is not a student, check this box.

Enter the Social Security Number for this household member.

Enter the full name of the fourth household member who lives with you.

Enter the relationship of the fourth household member to you (for example, spouse, child, parent, roommate).

Check this box if the fourth household member currently receives public assistance.

Check this box if the fourth household member does not receive public assistance.

Check this box if the fourth household member's sex is male.

Check this box if the fourth household member's sex is female.

Enter the birth date of the fourth household member who lives with you.

Check this box if the fourth household member is blind or has a disability.

Check this box if the fourth household member is not blind and does not have a disability.

Check this box if the fourth household member is under 22 and is married.

Check this box if the fourth household member is under 22 and is not married.

Check this box if the fourth household member is under 22 and is a student.

Check this box if the fourth household member is under 22 and is not a student.

Enter the Social Security Number of the fourth household member who lives with you.

Enter the full name (first, middle initial, last) of the second person who lives with you listed in row two.

Enter this person's relationship to you (for example: spouse, child, roommate, friend).

Check this box if the household member in the second row receives public assistance.

Check this box if the household member in the second row does not receive public assistance.

Check this box if the household member in the second row is male.

Check this box if the household member in the second row is female.

Enter the date of birth of the second household member.

Check this box if the household member in the second row is blind or disabled.

Check this box if the household member in the second row is not blind or disabled.

If the household member in the second row is under 22, check this box if they are married.

If the household member in the second row is under 22, check this box if they are not married.

If the household member in the second row is under 22, check this box if they are a student.

If the household member in the second row is under 22, check this box if they are not a student.

Provide the Social Security number for the second household member (enter all digits as issued).

Enter the full name of the sixth person who lives with you.

Enter how this sixth household member is related to you (for example: spouse, child, roommate).

Check this box if the sixth household member currently receives public assistance (YES).

Check this box if the sixth household member does not receive public assistance (NO).

Check this box if the sixth household member's sex is male (M).

Check this box if the sixth household member's sex is female (F).

Enter the birthdate of the sixth household member.

Check this box if the sixth household member is blind or has a disability (YES).

Check this box if the sixth household member is not blind and not disabled (NO).

If the sixth household member is under age 22 and is married, check this YES box.

If the sixth household member is under age 22 and is not married, check this NO box.

If the sixth household member is under age 22 and is a student, check this YES box.

If the sixth household member is under age 22 and is not a student, check this NO box.

Enter the Social Security Number (SSN) for the sixth household member.

Enter the full name of the third person who lives with you (first and last name).

Enter the relationship of the third household member to you (for example, spouse, child, roommate, friend).

Check this box if the household member listed in the third row receives public assistance.

Check this box if the household member listed in the third row does not receive public assistance.

Check this box if the household member listed in the third row is male.

Check this box if the household member listed in the third row is female.

Enter the date of birth of the third household member.

Check this box if the household member listed in the third row is blind or disabled.

Check this box if the household member listed in the third row is not blind or disabled.

If the household member listed in the third row is under age 22, check this box if they are married.

If the household member listed in the third row is under age 22, check this box if they are not married.

If the household member listed in the third row is under age 22, check this box if they are a student.

If the household member listed in the third row is under age 22, check this box if they are not a student.

Enter the Social Security Number (SSN) of the third household member.

Enter the full name of the person or entity who owns this item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Provide a brief name or description of the item (for example, 'savings account', 'car', or 'investment'). Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the monetary value of the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the full name and mailing address of the bank or other organization associated with this item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the account, identification, or reference number used by the bank or organization to identify this item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the full name of the person or entity who owns this item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the name or brief description of the item or asset being reported. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the dollar value of the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the full name and mailing address of the bank or organization associated with this item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the identifying account or reference number for this item (for example, account, policy, or other ID). Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the full name of the person who owns the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the name or brief description of the item being reported (for example, 'savings account', 'vehicle', or 'bond'). Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the monetary value of the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Provide the full name and mailing address of the bank or other organization associated with the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the account, policy, or other identifying number assigned to the item by the bank or organization. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the full name of the person who owns the listed item (first and last name). Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the common name or brief description of the item (for example: checking account, vehicle, bond, etc.). Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the current monetary value of the item in dollars as reported. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Provide the full name and mailing address of the bank or organization that holds or issued the item. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Enter the account, policy, or other identifying number associated with the item, including any letters or dashes. Fill only if 'any item in #42(a) (Stocks or Mutual Funds / Bonds / Promissory Notes / Other items that can be turned into cash)' is 'Yes'.

Check this box if you (the claimant) own or are currently buying any life insurance policies (if checked, go to item 43(b)).

Check this box if you (the claimant) do not own and are not buying any life insurance policies (if checked, go to item 44).

Check this box if your spouse does own or is buying any life insurance policies (then complete item (b)).

Check this box if your spouse does not own and is not buying any life insurance policies (then skip to #44).

Enter the full legal name of the owner of Policy (#1) as shown on the insurance documents. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the full name of the individual insured under Policy (#1). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Provide the full name and mailing address of the insurance company or organization that issued Policy (#1). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the identifying policy number for Policy (#1) exactly as it appears on the policy documents. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the face (death benefit) value amount for Policy (#1) as stated on the policy. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the current cash surrender value available for Policy (#1), if any. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the date when Policy (#1) was purchased. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #1 pays dividends (select 'Yes' for Dividends). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #1 does not pay dividends (select 'No' for Dividends). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if dividends for Policy #1 are left to accumulate (select 'Yes' for Accumulations). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if dividends for Policy #1 are not accumulated (select 'No' for Accumulations). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the full name of the owner of life insurance policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the full name of the person insured under policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the name and mailing address of the insurance company that issued policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the policy number or identifying code for policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the face (coverage) amount for policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the cash surrender value for policy #2. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the date when policy #2 was purchased. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #2 pays dividends (i.e., dividends are paid on this policy). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #2 does not pay dividends. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #2 has accumulations (dividends or values are being left to accumulate). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #2 does not have accumulations. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the full name of the owner of policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the full name of the person insured under policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Provide the name and mailing address of the insurance company that issued policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the identifying policy number assigned by the insurance company for policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the face (coverage) amount for policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the current cash surrender value for policy #3. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Enter the date policy #3 was purchased. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #3 pays dividends (select YES when dividends are paid on this policy). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #3 does not pay dividends (select NO when no dividends are paid on this policy). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #3 has accumulations (for example accumulated cash value or retained dividends). Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if Policy #3 does not have accumulations. Fill only if 'You — YES', 'Your Spouse - YES (Life Insurance)' is 'Yes' (any).

Check this box if you live either by yourself or only with your spouse; if checked, follow the form instruction to go to #27.

Check this box if you live with people other than your spouse (i.e., you do not live alone or only with your spouse); if checked, follow the form instruction to go to #26.

Check this box if you (or your spouse) have a loan currently outstanding against any life insurance policy, and then enter the policy number and loan amount in the space provided.

Enter the policy number for the loan taken against the life insurance policy as shown on the policy documents. Fill only if 'Loans Against Policy — YES' is 'Yes'.

Enter the current outstanding loan amount taken against the policy. Fill only if 'Loans Against Policy — YES' is 'Yes'.

Check this box if you (and your spouse) do not have any loans against any life insurance policies.

If you are blind or visually impaired, check this box when you want to receive the standard notice by First-Class mail.

If you are blind or visually impaired, check this box when you want the standard First-Class notice plus a follow-up phone call.

If you are blind or visually impaired, check this box when you want the standard notice and a data CD sent by First-Class mail.

If you are blind or visually impaired, check this box when you want the standard notice sent via certified mail.

If you are blind or visually impaired, check this box when you want both the standard notice and a Braille version sent by First-Class mail.

If you are blind or visually impaired, check this box when you want both the standard notice and a large-print version.

If you are blind or visually impaired, check this box when you want the standard notice and an audio CD.

Enter the average monthly amount you pay for mortgage or rent (show the average over the past 12 months, or for the months you have lived at your current address if less than 12 months). Fill only if 'Present living situation' is 'Household'.

Check this box if you have received or expect to receive insurance or annuity payments since the first moment of the filing date month or within the next 14 months.

Check this box if you have not received and do not expect to receive insurance or annuity payments since the first moment of the filing date month or within the next 14 months.

Check this box if your spouse has received or expects to receive insurance or annuity payments since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive insurance or annuity payments since the first moment of the filing date month or within the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if you (the applicant) have received or expect to receive Other Income Based on Need in the next 14 months.

Check this box if you (the applicant) have not received and do not expect to receive Other Income Based on Need in the next 14 months.

Check this box if your spouse has received or expects to receive Other Income Based on Need in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Check this box if your spouse has not received and does not expect to receive Other Income Based on Need in the next 14 months. Fill only if 'Are you married?' is 'Yes'.

Enter the full name of the non-institutional care facility where you currently live.

Enter the full name of the agency that placed you in the facility.

Enter the placing agency's complete mailing address, including street, city, state, and ZIP code.

Provide the placing agency's telephone number, including area code and extension if applicable.

Check this box if the placing agency pays for your room and board.

Check this box if the placing agency does not pay for your room and board, and then enter who pays in the space provided.

If the placing agency does not pay for your room and board, enter the name of the person or organization that pays.

Enter the office date stamp applied by Social Security staff indicating when the form was processed or received.

Enter the date the applicant (or SSA staff) filed this application.

Check this box when the office has issued a receipt to acknowledge the applicant's filing.

Check this box if a protective filing was made to preserve the applicant's filing date.

Check this box when the application was filed or processed through the SNAP-SSA/APP referral or application process.

Check this box if the applicant was referred to SSA/SSI by the SNAP program.

Enter the applicant's preferred written language for correspondence (for example, English or Spanish).

Enter the applicant's preferred spoken language for interviews or phone calls (for example, English or Spanish).

Check this box if you have ever used any other names (including a maiden name) or any other Social Security Number; if checked, continue to item (c).

Check this box if you have never used any other names or any other Social Security Number; if checked, continue to item (d).

Enter any other names you have used (for example, maiden, married, or alias names); include first, middle, and last names and list multiple names separated by commas. Fill only if 'Did you ever use any other names or Social Security Numbers? - YES' is 'Yes'.

Enter any other Social Security numbers you have ever used (if more than one, separate them with commas); include all previously assigned SSNs. Fill only if 'Did you ever use any other names or Social Security Numbers? - YES' is 'Yes'.

Enter the Office of Management and Budget (OMB) control/approval number shown for the Paperwork Reduction Act statement on this form.

Enter Parent 1's full current name(s) as used on official records (first name, middle initial, last name, and any suffix).

List any other names Parent 1 has used (for example maiden name, name at birth, previous legal names, or aliases), separated by commas.

Enter Parent 2's full current name(s) as used on official records (first name, middle initial, last name, and any suffix).

List any other names Parent 2 has used (for example maiden name, name at birth, previous legal names, or aliases), separated by commas.

Enter any explanations or additional remarks related to the form; include the item number before each explanation and provide free‑text details needed to clarify answers on earlier parts of the form. Fill only if 'Do you plan to attend school regularly during the next 4 months?' is 'Yes'.

Enter your initials or short acknowledgement indicating you have read and understand the Privacy Act Statement on this form.

Enter the average monthly amount you pay for property insurance (if required by your mortgage lender), showing the average over the past 12 months or for the months you have resided at your current address. Fill only if 'Present living situation' is 'Household'.

Check this box if you are a naturalized United States citizen; if checked, follow the form instruction to go to #15. Fill only if 'Q9 You - NO (not a United States citizen by birth)' is 'Yes'.

Check this box if you are not a naturalized United States citizen; if checked, follow the form instruction to go to #11. Fill only if 'Q9 You - NO (not a United States citizen by birth)' is 'Yes'.

Check this box if your spouse is a naturalized United States citizen; if checked, follow the form instruction to go to #15. Fill only if 'Q9 Your Spouse, if filing - NO (not a United States citizen by birth)' is 'Yes'.

Check this box if your spouse is not a naturalized United States citizen; if checked, follow the form instruction to go to #11. Fill only if 'Q9 Your Spouse, if filing - NO (not a United States citizen by birth)' is 'Yes'.

Check this box if you are an American Indian who was born outside the United States. Fill only if 'Q10 You - NO (Not a naturalized U.S. citizen)' is 'Yes'.

Check this box if you are not an American Indian born outside the United States. Fill only if 'Q10 You - NO (Not a naturalized U.S. citizen)' is 'Yes'.

If filing with a spouse, check this box if your spouse is an American Indian who was born outside the United States. Fill only if 'Q10 Spouse - NO (Not a naturalized U.S. citizen)' is 'Yes'.

If filing with a spouse, check this box if your spouse is not an American Indian born outside the United States. Fill only if 'Q10 Spouse - NO (Not a naturalized U.S. citizen)' is 'Yes'.

Check this box if you are an American Indian who was born in Canada (if checked, follow the form instruction to go to #15). Fill only if 'Q11(a) You - YES (American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse (if filing) is an American Indian who was born in Canada (if checked, follow the form instruction to go to #15). Fill only if 'Q11(a) Your Spouse - YES (American Indian born outside the United States)' is 'Yes'.

Check this box if you are a member of a federally recognized Indian tribe, then write the tribe name on the line and follow the form instructions (Go to #15). Fill only if 'Q11(a) You - YES (American Indian born outside the United States)' is 'Yes'.

Enter the full name of the federally recognized Indian tribe you are a member of (leave blank if not a member). Fill only if 'Q11(b) You - Member of a Federally recognized Indian Tribe; Name of Tribe' is 'Yes'.

Check this box if your spouse (if filing) is a member of a federally recognized Indian tribe, then write the tribe name on the line and follow the form instructions (Go to #15). Fill only if 'Q11(a) Your Spouse - YES (American Indian born outside the United States)' is 'Yes'.

Enter the full name of the federally recognized Indian tribe your spouse is a member of (leave blank if not a member or if spouse is not filing). Fill only if 'Q11(b) Your Spouse - Member of a Federally recognized Indian Tribe; Name of Tribe' is 'Yes'.

Check this box if you (the applicant) are an 'Other American Indian' not covered by the other options; provide an explanation in Remarks, then continue to (c). Fill only if 'Q11(a) You - YES (American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse (if filing) is an 'Other American Indian' not covered by the other options; provide an explanation in Remarks, then continue to (c). Fill only if 'Q11(a) Your Spouse - YES (American Indian born outside the United States)' is 'Yes'.

Check this box if your current immigration status is Amerasian Immigrant (if so, follow the form instructions to go to #12). Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse's current immigration status is Amerasian Immigrant (if so, follow the form instructions to go to #12). Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your current immigration status is Asylee; also provide the date your asylee status was granted on the line labeled 'Date status granted.' Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date when your asylum (asylee) status was granted. Fill only if 'Q11(c) Asylee (You)' is 'Yes'.

Check this box if your spouse’s current immigration status is Asylee; also provide the date your spouse’s asylee status was granted on the line labeled 'Date status granted.' Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date when your spouse's asylum (asylee) status was granted. Fill only if 'Q11(c) Asylee (Your Spouse, if filing)' is 'Yes'.

Check this box if your current immigration status is Conditional Entrant; enter the date the status was granted and then follow the form instruction to go to #14. Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date the conditional entrant status was granted to you. Fill only if 'Q11(c) Conditional Entrant (You)' is 'Yes'.

Check this box if your spouse's current immigration status is Conditional Entrant; enter the date the status was granted and then follow the form instruction to go to #14. Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date the conditional entrant status was granted to your spouse. Fill only if 'Q11(c) Conditional Entrant (Your Spouse, if filing)' is 'Yes'.

Check this box if your current immigration status is Cuban/Haitian Entrant. Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse’s current immigration status is Cuban/Haitian Entrant. Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your current immigration status is Deportation/Removal Withheld; also enter the date shown on the Date line next to this box and then follow the form's instruction to Go to #14. Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date when deportation or removal was withheld for you (the applicant). Fill only if 'Q11(c) Deportation/Removal Withheld (You)' is 'Yes'.

Check this box if your spouse's current immigration status is Deportation/Removal Withheld; also enter the date shown on the Date line next to this box and then follow the form's instruction to Go to #14. Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date when deportation or removal was withheld for your spouse, if they are filing. Fill only if 'Q11(c) Deportation/Removal Withheld (Your Spouse, if filing)' is 'Yes'.

Check this box if you are a Lawful Permanent Resident (green card holder) at the time you complete the form. Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse (the person filing with you) is a Lawful Permanent Resident (green card holder) at the time you complete the form. Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if you are currently paroled into the United States for a one-year period (Parolee for One Year). Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse (the person filing with you) is currently paroled into the United States for a one-year period (Parolee for One Year). Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your current immigration status is Refugee, then write your date of entry in the space provided and follow the form instructions (Go to #14). Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date you entered the United States as a refugee. Fill only if 'Refugee (You) — Date of entry' is 'Yes'.

Check this box if your spouse’s current immigration status is Refugee, then have them write their date of entry in the space provided and follow the form instructions (Go to #14). Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date your spouse entered the United States as a refugee. Fill only if 'Refugee (Your Spouse, if filing) — Date of entry' is 'Yes'.

Check this box if your current immigration status is unknown or does not fit any listed categories; then explain the status in Remarks and proceed to (d). Fill only if 'Q11(a) You - NO (Not an American Indian born outside the United States)' is 'Yes'.

Check this box if your spouse's current immigration status is unknown or does not fit any listed categories; then have them explain the status in Remarks and proceed to (d). Fill only if 'Q11(a) Your Spouse - NO (Not an American Indian born outside the United States)' is 'Yes'.

Enter the date you were lawfully admitted for permanent residence. Fill only if 'Q11(c) You - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - You' is 'Yes' (any).

Enter the date your spouse was lawfully admitted for permanent residence. Fill only if 'Q11(c) Your Spouse, if filing - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - Your Spouse, if filing' is 'Yes' (any).

Check this box if your entry into the United States was sponsored by any person or promoted by an institution or group. Fill only if 'Q11(c) You - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - You' is 'Yes' (any).

Check this box if your entry into the United States was not sponsored or promoted by any person, institution, or group. Fill only if 'Q11(c) You - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - You' is 'Yes' (any).

Check this box if your spouse's entry into the United States was sponsored by any person or promoted by an institution or group. Fill only if 'Q11(c) Your Spouse, if filing - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - Your Spouse, if filing' is 'Yes' (any).

Check this box if your spouse's entry into the United States was not sponsored or promoted by any person, institution, or group. Fill only if 'Q11(c) Your Spouse, if filing - Amerasian Immigrant', 'Q11(c) Lawful Permanent Resident - Your Spouse, if filing' is 'Yes' (any).

Enter the full name of the person, institution, or group that sponsored or promoted your entry into the United States. Fill only if 'Q12(b) You — YES', 'Q12(b) Your Spouse, if filing — YES' is 'Yes' (any).

Enter the sponsor's complete mailing address, including street, city, state/province, ZIP/postal code, and country. Fill only if 'Q12(b) You — YES', 'Q12(b) Your Spouse, if filing — YES' is 'Yes' (any).

Enter the sponsor's telephone number, including country and area code as needed so we can contact them. Fill only if 'Q12(b) You — YES', 'Q12(b) Your Spouse, if filing — YES' is 'Yes' (any).

Enter your immigration status, if any, that you held immediately before adjustment to lawful permanent resident.

Enter the date this immigration status began before you adjusted to lawful permanent resident.

Enter the date this immigration status ended before you adjusted to lawful permanent resident or the last date you held that status.

Enter your spouse's immigration status, if any, that they held immediately before adjustment to lawful permanent resident.

Enter the date your spouse's immigration status began before they adjusted to lawful permanent resident.

Enter the date your spouse's immigration status ended before they adjusted to lawful permanent resident or the last date they held that status.

Check this box if, when filing as an adult, at least one of your parents worked in the United States before you reached age 18.

Check this box if, when filing as an adult, none of your parents worked in the United States before you reached age 18.

Check this box if, when your spouse is filing as an adult, at least one of your spouse's parents worked in the United States before your spouse reached age 18.

Check this box if, when your spouse is filing as an adult, none of your spouse's parents worked in the United States before your spouse reached age 18.

Enter the full legal name (first, middle, and last as applicable) of the first parent who worked in the United States. Fill only if 'Q12(e) You - Parents worked in U.S. before age 18: YES' is 'Yes'.

Enter the Social Security Number of the first parent who worked in the United States. Fill only if 'Q12(e) You - Parents worked in U.S. before age 18: YES' is 'Yes'.

Enter the full name (first, middle, last) of the second parent who worked in the United States. Fill only if 'Q12(e) You - Parents worked in U.S. before age 18: YES' is 'Yes'.

Enter the second parent's Social Security Number (digits only) as shown on their Social Security card. Fill only if 'Q12(e) You - Parents worked in U.S. before age 18: YES' is 'Yes'.

Check this box if you (the applicant) or your child or your parent have been subjected to battery or extreme cruelty while in the United States.

Check this box if you (the applicant) and your child and your parent have not been subjected to battery or extreme cruelty while in the United States.

Check this box if your spouse (the filer in the 'Your Spouse' column) or their child or parent have been subjected to battery or extreme cruelty while in the United States.

Check this box if your spouse (the filer in the 'Your Spouse' column) and their child and their parent have not been subjected to battery or extreme cruelty while in the United States.

Check this box if you (or your child or your parent) have filed a Department of Homeland Security petition to change immigration status because of being subjected to battery or extreme cruelty.

Check this box if neither you nor your child or your parent have filed a Department of Homeland Security petition to change immigration status for reasons of battery or extreme cruelty.

Check this box if your spouse (if filing), or their child or parent, have filed a Department of Homeland Security petition to change immigration status because of being subjected to battery or extreme cruelty.

Check this box if neither your spouse (if filing) nor their child or parent have filed a Department of Homeland Security petition to change immigration status for reasons of battery or extreme cruelty.

Check this box if you are an active duty member or a veteran of the U.S. armed forces; if checked, explain in item #59(b) then continue to question #15.

Check this box if you are not an active duty member or a veteran of the U.S. armed forces, then proceed to question #15.

Check this box if your spouse (if filing) is an active duty member or a veteran of the U.S. armed forces; if checked, explain in item #59(b) then continue to question #15.

Check this box if your spouse (if filing) is not an active duty member or a veteran of the U.S. armed forces, then proceed to question #15.

Enter the date when you first made your home in the United States.

Enter the date when your spouse (if filing) first made their home in the United States.

Check this box if you have lived outside the United States at any time since you first made your home in the United States.

Check this box if you have not lived outside the United States since you first made your home in the United States.

Check this box if your spouse (if filing) has lived outside the United States at any time since they first made their home in the United States.

Check this box if your spouse (if filing) has not lived outside the United States since they first made their home in the United States.

Enter the date you began residing outside the United States for this reported period. Fill only if '15(b) You — YES (Lived outside the United States since then)' is 'Yes'.

Enter the date you stopped residing outside the United States for this reported period. Fill only if '15(b) You — YES (Lived outside the United States since then)' is 'Yes'.

Enter the date your spouse began residing outside the United States for this reported period. Fill only if '15(b) Your Spouse, if filing — YES (Lived outside the United States since then)' is 'Yes'.

Enter the date your spouse stopped residing outside the United States for this reported period. Fill only if '15(b) Your Spouse, if filing — YES (Lived outside the United States since then)' is 'Yes'.

Check this box if you were outside the United States (the 50 states, District of Columbia, and Northern Mariana Islands) for 30 consecutive days immediately before the filing date.

Check this box if you were not outside the United States for 30 consecutive days immediately before the filing date.

Check this box if your spouse (if filing) was outside the United States (the 50 states, District of Columbia, and Northern Mariana Islands) for 30 consecutive days immediately before the filing date.

Check this box if your spouse (if filing) was not outside the United States for 30 consecutive days immediately before the filing date.

Enter the date you left the United States for the trip being reported. Fill only if 'Q16(a) You — YES' is 'Yes'.

Enter the date you returned to the United States from the trip being reported. Fill only if 'Q16(a) You — YES' is 'Yes'.

Enter the date your spouse left the United States for the trip being reported. Fill only if 'Q16(a) Your Spouse, if filing — YES' is 'Yes'.

Enter the date your spouse returned to the United States from the trip being reported. Fill only if 'Q16(a) Your Spouse, if filing — YES' is 'Yes'.

Check this box if your spouse or parent is the sponsor of an alien who is eligible for supplemental security income (then complete (b)). Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents' or 'Individual with Ineligible Spouse'.

Check this box if your spouse or parent is not the sponsor of an alien who is eligible for supplemental security income (then skip to question 18). Fill only if 'TYPE OF CLAIM' is 'Child' or 'Child with Parents' or 'Individual with Ineligible Spouse'.

Enter the eligible alien's full legal name (first, middle, and last) as it should appear on official records. Fill only if 'Q17(a) Sponsor of Eligible Alien — YES' is 'Yes'.

Enter the eligible alien's Social Security Number using digits (for example, 123-45-6789). Fill only if 'Q17(a) Sponsor of Eligible Alien — YES' is 'Yes'.

Check this box if you have any unsatisfied felony warrants for your arrest (if checked, go to (b)).

Check this box if you do not have any unsatisfied felony warrants for your arrest (if checked, go to #19).

Check this box if your spouse (if filing) has any unsatisfied felony warrants for their arrest (if checked, go to (b)). Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse (if filing) does not have any unsatisfied felony warrants for their arrest (if checked, go to #19). Fill only if 'TYPE OF CLAIM' is 'Couple'.

Enter the name of the state or country where the unsatisfied felony warrant for you was issued. Fill only if 'Q18(a) You — YES (Unsatisfied felony warrant)' is 'Yes'.

Enter the name of the state or country where the unsatisfied felony warrant for your spouse (if filing) was issued. Fill only if 'Q18(a) Your Spouse, if filing — YES (Unsatisfied felony warrant)' is 'Yes'.

Check this box if the warrant for your arrest was satisfied (resolved or cleared). Fill only if 'Q18(a) You — YES (Unsatisfied felony warrant)' is 'Yes'.

Check this box if the warrant for your arrest was NOT satisfied (still outstanding). Fill only if 'Q18(a) You — YES (Unsatisfied felony warrant)' is 'Yes'.

Check this box if the warrant for your spouse's arrest was satisfied (resolved or cleared). Fill only if 'Q18(a) Your Spouse, if filing — YES (Unsatisfied felony warrant)' is 'Yes'.

Check this box if the warrant for your spouse's arrest was NOT satisfied (still outstanding). Fill only if 'Q18(a) Your Spouse, if filing — YES (Unsatisfied felony warrant)' is 'Yes'.

Enter the date the felony warrant for your arrest was satisfied. Fill only if 'You — YES (Was the warrant satisfied?)' is 'Yes'.

Enter the date the felony warrant for your spouse was satisfied (if your spouse is filing). Fill only if 'Your Spouse, if filing — YES (Was the warrant satisfied?)' is 'Yes'.

Check this box if your present living situation is 'Household' and enter the date (MM/DD/YYYY) since you have been in that living situation.

Enter the date you began living in the household listed as your present living situation. Fill only if 'Q19 First - Household (Since Date)' is selected.

Check this box if your present living situation at the signature date is transient or homeless, and then enter the date since when this has been your living situation (MM/DD/YYYY).

Enter the date you began living as transient or homeless. Fill only if 'Q19 Fourth - Transient or homeless' is selected.

Check this box if your current living situation is non‑institutional care; also provide the date you began living there in the 'Since (MM/DD/YYYY)' field.

Enter the date you began living in the non‑institutional care situation listed in this row. Fill only if 'Q19 Second - Non-Institutional Care (Since Date)' is selected.

Check this box if your present living situation is 'Institution' as of the signature date; enter the date you began living there in the 'Since (MM/DD/YYYY)' field.

Enter the date you began living in an institution for the third listed living situation. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a school. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a hospital. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a rest or retirement home. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a nursing home. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a rehabilitation center. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is a jail. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if the institution where you currently reside is not listed above and you will specify the type. Fill only if 'Third - Institution (Since Date)' is selected.

If your institution type is not listed, enter the name or brief description of the institution type here (e.g., assisted living, group home). Fill only if 'Third - Institution (Since Date)', 'Q20 - Other (Specify)' are selected (all).

Enter the full legal name of the institution where you currently reside or are admitted. Fill only if 'Third - Institution (Since Date)' is selected.

Provide the date you were admitted to the institution. Fill only if 'Third - Institution (Since Date)' is selected.

Provide the date you expect to be released or discharged from the institution. Fill only if 'Third - Institution (Since Date)' is selected.

Check this box if your current non-institutional residence is a foster home (then follow the form instructions to go to #23). Fill only if 'Q19 Second - Non-Institutional Care (Since Date)' is selected.

Check this box if your current non-institutional residence is a group home (then follow the form instructions to go to #23). Fill only if 'Q19 Second - Non-Institutional Care (Since Date)' is selected.

Check this box if your current non-institutional residence is a type not listed (Other) and provide the specific residence type (then follow the form instructions to go to #23). Fill only if 'Q19 Second - Non-Institutional Care (Since Date)' is selected.

Enter the name or description of the 'Other' non-institutional residence where you currently live (for example, boarding house, assisted living, or specific facility name). Fill only if 'Q19 Second - Non-Institutional Care (Since Date)', 'Q22 Other (Specify)' are selected (all).

Check this box if anyone listed in Q26(a) who is under age 18, or who is between ages 18–22 and a student, receives any income. Fill only if 'Q26(a) (everyone who lives with you) includes anyone under age 22 and not married' is 'Yes'.

Check this box if none of the persons listed in Q26(a) who are under age 18 or who are ages 18–22 and students receive any income. Fill only if 'Q26(a) (everyone who lives with you) includes anyone under age 22 and not married' is 'Yes'.

Check this box if you or anyone who lives with you owns or rents the place where you live (then follow the form instructions to go to #28).

Check this box if neither you nor anyone who lives with you owns or rents the place where you live (then follow the form instructions to go to 27(b)).

Enter the full name of the person who owns or rents the place where you live. Fill only if 'Q27(a) NO - Do not own or rent the place where you live' is 'Yes'.

Enter the complete street address (including apartment or unit number if applicable), city, state, and ZIP code for the person who owns or rents the place where you live. Fill only if 'Q27(a) NO - Do not own or rent the place where you live' is 'Yes'.

Enter a telephone number where the person who owns or rents the place where you live can be reached. Fill only if 'Q27(a) NO - Do not own or rent the place where you live' is 'Yes'.

Check this box if you (or your spouse) are buying or you own the place where you live (then go to (c)).

Check this box if you (or your spouse) do not buy or own the place where you live (if you are a child living with your parent(s) go to (b); otherwise go to #29).

Check this box if your parent(s) are buying or they own the place where you live (then go to (c)).

Check this box if your parent(s) do not buy or own the place where you live (then go to #29).

Enter the dollar amount of the mortgage payment you make for the place where you live. Fill only if 'Q28(a) YES', 'Q28(b) YES' is 'Yes' for any fields selection.

Enter how often the mortgage payment is made (for example, monthly, weekly, biweekly, or annually). Fill only if 'Q28(a) YES', 'Q28(b) YES' is 'Yes' for any fields selection.

Check this box if you (or the spouse living with you) are legally responsible for paying rent for the place where you live.

Check this box if neither you nor the spouse living with you are responsible for paying rent for the place where you live (if you are a child living with your parent(s) go to (b); otherwise go to (c)).

Check this box if your parent(s) are legally responsible for paying rent for the place where they live.

Check this box if your parent(s) are not responsible for paying rent for their residence (proceed to (c)).

Check this box if someone who lives with you has rental liability and you will provide that person's name on the line.

Enter the full name of the person who has rental liability for the place where you live. Fill only if 'Q29(c) YES — Someone who lives with me has rental liability' is 'Yes'.

Check this box if no one who lives with you has rental liability and you will provide the name of the person who owns the home.

Enter the full name of the person who has home ownership (the homeowner) for the place where you live. Fill only if 'Q29(c) NO — No one who lives with me has rental liability (give name of person with home ownership)' is 'Yes'.

Provide the amount of rent paid for the residence. Fill only if 'Q29(a) YES — I (or my spouse living with me) have rental liability', 'Q29(b) YES — Parent(s) have rental liability' is 'Yes' for any.

Enter how often the rent is paid (for example: monthly, weekly, biweekly, or annually). Fill only if 'Q29(a) YES — I (or my spouse living with me) have rental liability', 'Q29(b) YES — Parent(s) have rental liability' is 'Yes' for any.

Check this box if you or anyone who lives with you is the parent or child of the landlord or the landlord's spouse (if checked, continue to item (b)).

Check this box if neither you nor anyone who lives with you is the parent or child of the landlord or the landlord's spouse (if checked, follow the form instruction to go to item (c)).

Enter the relationship of the person related to the landlord or the landlord's spouse (for example, parent, child, spouse, sibling, etc.). Fill only if 'Q30(a) YES — Parent or child of landlord or landlord's spouse' is 'Yes'.

Provide the landlord's full name and mailing address and, if known, their telephone number and area code. Fill only if 'Q30(a) YES — Parent or child of landlord or landlord's spouse' is 'Yes'.

Check this box if anyone living with you contributes money or pays household expenses for your household.

Check this box if no one living with you contributes money or pays household expenses for your household.

Enter the total dollar amount that other people living with you contribute toward household expenses for question 31(b). Fill only if 'Q31(a) YES - Others contribute to household expenses' is 'Yes'.

Check this box if others in the household pay for or provide you with all of your meals.

Check this box if others in the household do not pay for or provide you with all of your meals (you receive some or none from others).

Check this box if you do contribute to household expenses; also enter the average monthly amount you contribute.

Enter the average monthly dollar amount you contribute toward household expenses. Fill only if 'Q33 YES — Average Monthly Amount' is 'Yes'.

Check this box if you do not contribute to household expenses.

Check this box if you do have a loan agreement with anyone to repay the value of your share of the household expenses.

Check this box if you do not have a loan agreement with anyone to repay the value of your share of the household expenses.

Enter the full name, street address, and telephone number (including area code) of the person or entity with whom you have the loan agreement to repay your share of household expenses. Fill only if 'Q34(a) Loan agreement - YES' is 'Yes'.

Check this box if the amount of the loan will cover your share of the household expenses.

Check this box if the amount of the loan will not cover your share of the household expenses.

Check this box if someone who does NOT live with you pays for, or provides you or your household any shelter items; then enter the provider's name, list of items, and monthly value.

Enter the full name of the person or agency that does NOT live with you and who pays for or provides shelter items for you or your household. Fill only if '36(a) YES — Name of Provider (Person or Agency)' is 'Yes'.

List each shelter-related item (for example, rent, utilities, repairs, furniture, or other housing costs) that the non-household provider pays for or supplies. Fill only if '36(a) YES — Name of Provider (Person or Agency)' is 'Yes'.

Enter the total monthly dollar value provided by the non-household person or agency toward the shelter items you listed. Fill only if '36(a) YES — Name of Provider (Person or Agency)' is 'Yes'.

Check this box if no one who does NOT live with you pays for or provides any of your or your household's shelter items.

Check this box if someone who does NOT live with you gives you or your household money to pay for any of your or your household's shelter items (then provide the name of the provider, list of items, and monthly value).

Enter the full name of the person or agency (who does NOT live with you) that gives money to your household for shelter items. Fill only if 'Q36(b) YES - Non-household gives money for shelter items' is 'Yes'.

List the shelter items (for example: rent, utilities, mortgage, insurance) that this non-household provider pays for or gives money toward. Fill only if 'Q36(b) YES - Non-household gives money for shelter items' is 'Yes'.

Enter the total monthly dollar value of the money or payments this provider gives toward your household's shelter items. Fill only if 'Q36(b) YES - Non-household gives money for shelter items' is 'Yes'.

Check this box if no one who does NOT live with you gives you or your household money to pay for any of your or your household's shelter items.

Check this box if the information provided in items #19–36 has been the same since the first moment of the filing date month.

Check this box if any information in items #19–36 has changed since the first moment of the filing date month (you must explain the changes in Remarks, then continue to part (b)).

Check this box if you expect any of the information given in items #19-36 to change; if checked, explain the changes in the Remarks section and then go to #38.

Check this box if you do not expect any of the information given in items #19-36 to change, then go to #38.

Enter the full title or official name of the trust in which your name appears. Fill only if 'Q38(a) You — Yes', 'Q38(a) Your Spouse — Yes' is 'Yes' (any).

Describe the trust's funding source (for example, self-funded, third-party funded, or another funding arrangement). Fill only if 'Q38(a) You — Yes', 'Q38(a) Your Spouse — Yes' is 'Yes' (any).

Provide the date when the trust was originally established. Fill only if 'Q38(a) You — Yes', 'Q38(a) Your Spouse — Yes' is 'Yes' (any).

Enter the total alleged monetary value of the assets held in the trust. Fill only if 'Q38(a) You — Yes', 'Q38(a) Your Spouse — Yes' is 'Yes' (any).

List the specific assets contained in the trust, such as vehicles, real estate, bank accounts, or other property. Fill only if 'Q38(a) You — Yes', 'Q38(a) Your Spouse — Yes' is 'Yes' (any).

Check this box if you (the applicant) own or your name appears, either alone or with other people, on any trust at the first moment of the filing date month.

Check this box if you (the applicant) do not own and your name does not appear on any trust at the first moment of the filing date month.

Check this box if your spouse owns or your spouse's name appears, either alone or with other people, on any trust at the first moment of the filing date month. Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Check this box if your spouse does not own and your spouse's name does not appear on any trust at the first moment of the filing date month. Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Check this box if, at the first moment of the filing date month, you own or your name appears (alone or with another person) on the title of any vehicle (auto, truck, motorcycle, camper, boat, etc.).

Check this box if, at the first moment of the filing date month, you do not own and your name does not appear on the title of any vehicle.

Check this box if, at the first moment of the filing date month, your spouse owns or your spouse's name appears (alone or with another person) on the title of any vehicle (auto, truck, motorcycle, camper, boat, etc.). Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Check this box if, at the first moment of the filing date month, your spouse does not own and your spouse's name does not appear on the title of any vehicle. Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Enter a clear description of the property (size, address or location, and how it is used), including when it was last used if not currently used and whether you plan to use the property in the future. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Enter a full description of the Item #2 property, including size, address or location, how it is used, when it was last used (if not in use now), and whether you plan to use the property in the future. Fill only if 'Q40 You - YES', 'Q40 Your Spouse - YES' is 'Yes' (any).

Check this box if you own, or your name appears (alone or with another person's name) on any land, houses, buildings, real property, property in a foreign country, equipment, mineral rights, items in a safe deposit box, assets set aside for emergencies or heirs, or any other property not shown elsewhere on the application.

Check this box if you do not own and your name does not appear on any of the types of property listed in Q40(a).

Check this box if your spouse (if filing) owns, or their name appears (alone or with another person's name) on any of the property types listed in Q40(a). Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Check this box if your spouse (if filing) does not own and their name does not appear on any of the types of property listed in Q40(a). Fill only if 'TYPE OF CLAIM - Couple' is 'Yes'.

Check this box if there has been any increase or decrease in the value of your or your spouse's resources since the first moment of the filing date month (if checked, follow instructions to complete item 44(d)).

Check this box if there has been no increase or decrease in the value of your or your spouse's resources since the first moment of the filing date month (if checked, proceed to item 45).

Provide a brief explanation describing any increase or decrease in the value of your or your spouse’s resources since the first moment of the filing date month, including what changed and when. Fill only if 'Q44(c) YES' is 'Yes'.

Check this box if you (the applicant) own items that were acquired or are held for their value as an investment.

Check this box if you (the applicant) do not own any items that were acquired or are held for their value as an investment.

Check this box if your spouse owns items that were acquired or are held for their value as an investment. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse does not own any items that were acquired or are held for their value as an investment. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if you (either alone or jointly with any other person) own a life estate or have an ownership interest in an unprobated estate.

Check this box if you do not own any life estate or ownership interest in an unprobated estate.

Check this box if your spouse (either alone or jointly with any other person) owns a life estate or has an ownership interest in an unprobated estate. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Check this box if your spouse does not own any life estate or ownership interest in an unprobated estate. Fill only if 'TYPE OF CLAIM' is 'Couple'.

Enter the full name of the person who owns the asset or investment listed in Row 1. Fill only if 'Q45(a) You - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Your Spouse - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Items acquired or held for their value as an investment? — You: YES', 'Q45(a) Items acquired or held for their value as an investment? — Your Spouse: YES' is 'Yes' (any).

Enter the name or brief description of the asset or investment for Row 1 (for example, type of account, property description, or security name). Fill only if 'Q45(a) You - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Your Spouse - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Items acquired or held for their value as an investment? — You: YES', 'Q45(a) Items acquired or held for their value as an investment? — Your Spouse: YES' is 'Yes' (any).

Enter the current total value of the item or investment listed in Row 1. Fill only if 'Q45(a) You - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Your Spouse - Life estates or ownership interest in an unprobated estate - YES', 'Q45(a) Items acquired or held for their value as an investment? — You: YES', 'Q45(a) Items acquired or held for their value as an investment? — Your Spouse: YES' is 'Yes' (any).