TN 15 (02-90)

1163. Situation Where Used:

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

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

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

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

   Choice 4 - you and your spouse are

   Choice 5 - she and her spouse are

   Choice 6 - he and his spouse are

   Choice 7 - you were

   Choice 8 - she was

   Choice 9 - he was

   Choice 10 - you and your spouse were

   Choice 11 - she and her spouse were

   Choice 12 - he and his spouse were

    

4. Choice 1 - living independently

   Choice 2 - living independently with cooking facilities

   Choice 3 - living independently without cooking facilities

   Choice 4 - living in the household of another

   Choice 5 - living with others

   Choice 6 - living with one or two persons

   Choice 7 - living with three or more persons

   Choice 8 - living with a dependent person

   Choice 9 - living with an ineligible spouse

   Choice 10 - living alone or purchasing room and board

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

   Choice 12 - in domiciliary care

   Choice 13 - in domiciliary care level I

   Choice 14 - in domiciliary care level II

   Choice 15 - in domiciliary care level III

   Choice 16 - in an adult foster care home

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

   Choice 18 - in an adult foster care and boarding home

   Choice 19 - in a home for the aged

   Choice 20 - in a private nonmedical group home

   Choice 21 - in licensed custodial care

   Choice 22 - in unlicensed custodial care

   Choice 23 - in congregate care level I

   Choice 24 - in congregate care level II

   Choice 25 - in congregate care level III

   Choice 26 - in a licensed boarding home for sheltered care

   Choice 27 - in a licensed developmentally disabled home level II

   Choice 30 - in a licensed developmentally disabled home level III

   Choice 31 - in a licensed developmentally disabled home level IV

   Choice 32 - in a licensed developmentally disabled home level V

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

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

   Choice 35 - receiving personal care

   Choice 36 - receiving nonmedical board and care

   Choice 37 - receiving adult residential care

   Choice 36 - receiving supervised licensed custodial care

   Choice 37 - sharing living expenses

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

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

   Choice 40 - in adult foster care—over 50 beds

   Choice 41 - living independently with an essential person

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

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

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

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

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

   Choice 47 - living alone or with others

   Choice 48 - living in a residential care facility

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

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

   Choice 51 - living in a foster care home

   Choice 52 - living in a semi-independent care facility

   Choice 53 - in a licensed foster home

   Choice 54 - in a licensed boarding home

   Choice 55 - in a cost-reimbursement home

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

   Choice 57 - Null

    

5. Choice 1 - for (Month/Year)

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

   Choice 3 - for (Month/Year) on

    

6. Choice 1 - ,

   Choice 2 - and

   Choice 3 - Null

    

7. Choice 1 - and your spouse is

   Choice 2 - and her spouse is

   Choice 3 - and his spouse is

   Choice 4 - and your spouse was

   Choice 5 - and her spouse was

   Choice 6 - and his spouse was

   Choice 7 - Null

    

8. Choice 1 - living independently

   Choice 2 - living independently with cooking facilities

   Choice 3 - living independently without cooking facilities

   Choice 4 - living in the household of another

   Choice 5 - living with others

   Choice 6 - living with one or two persons

   Choice 7 - living with three or more persons

   Choice 8 - living with a dependent person

   Choice 9 - living with an ineligible spouse

   Choice 10 - living alone or purchasing room and board

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

   Choice 12 - in domiciliary care

   Choice 13 - in domiciliary care level I

   Choice 14 - in domiciliary care level II

   Choice 15 - in domiciliary care level III

   Choice 16 - in an adult foster care home

   Choice 17 - in a family life home approved by State

   Choice 18 - in an adult foster care and boarding home

   Choice 19 - in a home for the aged

   Choice 20 - in a private nonmedical group home

   Choice 21 - in licensed custodial care

   Choice 22 - in unlicensed custodial care

   Choice 23 - in congregate care level I

   Choice 24 - in congregate care level II

   Choice 25 - in congregate care level III

   Choice 26 - in a licensed boarding home for sheltered care

   Choice 27 - in a licensed developmentally disabled home level II

   Choice 28 - in a licensed developmentally disabled home level III

   Choice 29 - in a licensed developmentally disabled home level IV

   Choice 30 - in a licensed developmentally disabled home level V

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

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

   Choice 33 - receiving personal care

   Choice 34 - receiving nonmedical board and care

   Choice 35 - receiving adult residential care

   Choice 36 - receiving supervised licensed custodial care

   Choice 37 - sharing living expenses

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

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

   Choice 40 - in adult foster care—over 50 beds

   Choice 41 - living independently with an essential person

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

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

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

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

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

   Choice 47 - living alone or with others

   Choice 48 - living in a residential care facility

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

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

   Choice 51 - living in a foster care home

   Choice 52 - living in a semi-independent care facility

   Choice 53 - in a licensed foster home

   Choice 54 - in a licensed boarding home

   Choice 55 - in a cost-reimbursement home

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

   Choice 57 - Null

    

9. Choice 1 - for (Month/Year)

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

   Choice 3 - for (Month/Year) on

    

10. Choice 1- ,

    Choice 2 - and

    Choice 3 - .

     

1164. Situation Where Used:

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

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

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

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - you are

   Choice 2 - you and your spouse are

   Choice 3 - she is

   Choice 4 - she and her spouse are

   Choice 5 - he is

   Choice 6 - he and his spouse are

   Choice 7 - you were

   Choice 8 - you and your spouse were

   Choice 9 - she was

   Choice 10 - she and her spouse were

   Choice 11 - he was

   Choice 12 - he and his spouse were

    

4. Choices under paragraph 1163 (4).

    

5. Choice 1 - for (Month/Year)

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

   Choice 3 - for (Month/Year) on

    

6. Choice 1 - ,

   Choice 2 - and

   Choice 3 - Null

    

7. Choice 1 - and your spouse is

   Choice 2 - and her spouse is

   Choice 3 - and his apouse is

   Choice 4 - and your spouse was

   Choice 5 - and her spouse was

   Choice 6 - and his spouse was

    

8. Choices under paragraph 1163 (4).

    

9. Choice 1 - for (Month/Year)

   Choice 3 - for (Month/Year) on

    

10. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

1310. Situation Where Used:

Denial of State supplement payments.

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

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

2. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

1311. Situation Where Used:

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

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

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

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. Choice 1 - you qualify

   Choice 2 - she qualifies

   Choice 3 - he qualifies

    

1312. Situation Where Used:

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

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

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

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

   Choice 4 - You and your spouse

   Choice 5 - She and her spouse

   Choice 6 - He and his spouse

   Choice 7 - Your spouse

   Choice 8 - Her spouse

   Choice 9 - His spouse

    

2. Choice 1 - are

   Choice 2 - is

   Choice 3 - were

   Choice 4 - was

    

3. Choice 1 - county of Albany in the

   Choice 2 - county of Allegany in the

   Choice 3 - county of Bronx in the

   Choice 4 - county of Broome in the

   Choice 5 - county of Cattarugus in the

   Choice 6 - county of Cayuga in the

   Choice 7 - county of Chautauqua in the

   Choice 8 - county of Chemung in the

   Choice 9 - county of Chenango in the

   Choice 10 - county of Clinton in the

   Choice 11 - county of Columbia in the

   Choice 12 - county of Courtland in the

   Choice 13 - county of Delaware in the

   Choice 14 - county of Dutchess in the

   Choice 15 - county of Erie in the

   Choice 16 - county of Essex in the

   Choice 17 - county of Franklin in the

   Choice 18 - county of Fulton in the

   Choice 19 - county of Genesee in the

   Choice 20 - county of Greene in the

   Choice 21 - county of Hamilton in the

   Choice 22 - county of Herkimer in the

   Choice 23 - county of Jefferson in the

   Choice 24 - county of Kings in the

   Choice 25 - county of Lewis in the

   Choice 26 - county of Livingston in the

   Choice 27 - county of Madison in the

   Choice 28 - county of Monroe in the

   Choice 29 - county of Montgomery in the

   Choice 30 - county of Nassau in the

   Choice 31 - county of New York in the

   Choice 32 - county of Niagara in the

   Choice 33 - county of Oneida in the

   Choice 34 - county of Onondago in the

   Choice 35 - county of Ontario in the

   Choice 36 - county of Orange in the

   Choice 37 - county of Orleans in the

   Choice 38 - county of Oswego in the

   Choice 39 - county of Otsego in the

   Choice 40 - county of Putnam in the

   Choice 41 - county of Queens in the

   Choice 42 - county of Rensselaer in the

   Choice 43 - county of Richmond in the

   Choice 44 - county of Rockland in the

   Choice 45 - county of St. Lawrence in the

   Choice 46 - county of Saratoga in the

   Choice 47 - county of Schenectady in the

   Choice 48 - county of Schoharie in the

   Choice 49 - county of Schuyler in the

   Choice 50 - county of Seneca in the

   Choice 51 - county of Steuben in the

   Choice 52 - county of Suffolk in the

   Choice 53 - county of Sullivan in the

   Choice 54 - county of Tioga in the

   Choice 55 - county of Tompkins in the

   Choice 56 - county of Ulster in the

   Choice 57 - county of Warren in the

   Choice 58 - county of Washington in the

   Choice 59 - county of Wayne in the

   Choice 60 - county of Westchester in the

   Choice 61 - county of Wyoming in the

   Choice 62 - county of Yates in the

   Choice 63 - Null

    

4. Choice 1 - county of Adams in the

   Choice 2 - county of Asotin in the

   Choice 3 - county of Benton in the

   Choice 4 - county of Chelan in the

   Choice 5 - county of Clallam in the

   Choice 6 - county of Clark in the

   Choice 7 - county of Columbia in the

   Choice 8 - county of Cowlitz in the

   Choice 9 - county of Douglas in the

   Choice 10 - county of Ferry in the

   Choice 11 - county of Franklin in the

   Choice 12 - county of Garfield in the

   Choice 13 - county of Grant in the

   Choice 14 - county of Grays Harbor in the

   Choice 15 - county of Island in the

   Choice 16 - county of Jefferson in the

   Choice 17 - county of King in the

   Choice 18 - county of Kitsap in the

   Choice 19 - county of Kittitas in the

   Choice 20 - county of Klickitat in the

   Choice 21 - county of Lewis in the

   Choice 22 - county of Lincoln in the

   Choice 23 - county of Mason in the

   Choice 24 - county of Okanogan in the

   Choice 25 - county of Pacific in the

   Choice 26 - county of Pend Oreille in the

   Choice 27 - county of Pierce in the

   Choice 28 - county of San Juan in the

   Choice 29 - county of Skagit in the

   Choice 30 - county of Skamania in the

   Choice 31 - county of Snohomish in the

   Choice 32 - county of Spokane in the

   Choice 33 - county of Stevens in the

   Choice 34 - county of Thurston in the

   Choice 35 - county of Wahkiakum in the

   Choice 36 - county of Walla Walla in the

   Choice 37 - county of Whatcom in the

   Choice 38 - county of Whitman in the

   Choice 39 - county of Yakima in the

   Choice 40 - Null

    

5. Choice 1 - State of (State name)

   Choice 2 - District of Columbia

   Choice 3 - Null

    

6. Choice 1 - for (Month/Year)

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

   Choice 3 - for (Month/Year) on

    

7. Choice 1 - , in the

   Choice 2 - and in the

   Choice 3 - .

   Choice 4 - ,

   Choice 5 - and

    

1313. Situation Where Used:

Individual waives State supplement.

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

1. Choice 1 - State of (State name)

   Choice 2 - District of Columbia

   Choice 3 - Null

    

2. Choice 1 - you

   Choice 2 - (Name of Recipient)

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your State

   Choice 2 - the District of Columbia

   Choice 3 - the State

    

5. Choice 1 - you later decide you wish

   Choice 2 - she later decides she wishes

   Choice 3 - he later decides he wishes

    

2310. Situation Where Used:

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

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

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. (Month/Year)

    

4. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

5. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

6. Choice 1 - State of       

   Choice 2 - District of Columbia

    

2311. Situation Where Used

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

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

1. Choice 1 - You are

   Choice 2 - She is

   Choice 3 - He is

    

2. Choice 1 - State of            

   Choice 2 - District of Columbia

    

3. (Month/Year)

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

5. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2312. Situation Where Used:

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

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

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - State of            

   Choice 2 - District of Columbia

    

3. (Month/Year)

    

4. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

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

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

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

    

2313. Situation Where Used:

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

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

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

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

4. Choice 1 - SSI

   Choice 2 - Null

    

5. Choice 1 - your State

   Choice 2 - her State

   Choice 3 - his State

   Choice 4 - the District of Columbia

    

6. Choice 1 - Your State

   Choice 2 - Her State

   Choice 3 - His State

   Choice 4 - The District of Columbia

    

7. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

8. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

9. Choice 1 - State

   Choice 2 - District of Columbia

    

2314. Situation Where Used:

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

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

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

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. Choice 1 - Your State

   Choice 2 - Her State

   Choice 3 - His State

   Choice 4 - The District of Columbia

    

4. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

5. Choice 1 - SSI

   Choice 2 - Null

    

2315. Situation Where Used:

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

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

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

1. Choice 1 - You have

   Choice 2 - She has

   Choice 3 - He has

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. Choice 1 - Your State

   Choice 2 - Her State

   Choice 3 - His State

   Choice 4 - The District of Columbia

    

4. Choice 1 - your SSI

   Choice 2 - her SSI

   Choice 3 - his SSI

    

5. (Month/Year)

    

6. Choice 1 - SSI

   Choice 2 - Null

    

7. Choice 1 - you from your State

   Choice 2 - her from her State

   Choice 3 - him from his State

   Choice 4 - you from the District of Columbia

   Choice 5 - her from the District of Columbia

   Choice 6 - him from the District of Columbia

    

2316. Situation Where Used:

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

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

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

1. Choice 1 - You have

   Choice 2 - She has

   Choice 3 - He has

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. Choice 1 - Your State

   Choice 2 - Her State

   Choice 3 - His State

   Choice 4 - The District of Columbia

    

4. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

5. (Month/Year)

    

6. Choice 1 - SSI

   Choice 2 - Null

    

7. Choice 1 - you from your State

   Choice 2 - her from her State

   Choice 3 - him from his State

   Choice 4 - you from the District of Columbia

   Choice 5 - her from the District of Columbia

   Choice 6 - him from the District of Columbia

    

2317. Situation Where Used:

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

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

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - you, your

   Choice 2 - her, her

   Choice 3 - him, his

    

3. Choice 1 - increased

   Choice 2 - reduced

   Choice 3 - stopped

    

4. (Month/Year)

    

2318. Situation Where Used:

Special need reduction reported.

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

1. Choice 1 - You no longer need

   Choice 2 - She no longer needs

   Choice 3 - He no longer needs

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. (Month/Year)

    

2325. Situation Where Used:

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

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

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

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

1. Choice 1 - been paying you Supplemental Security Income

   Choice 2 - been paying her Supplemental Security Income

   Choice 3 - been paying him Supplemental Security Income

   Choice 4 - you eligible under the Supplemental Security Income program

   Choice 5 - her eligible under the Supplemental Security Income program

   Choice 6 - him eligible under the Supplemental Security Income program

    

2. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

3. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

4. Choice 1 - Your eligibility for payments

   Choice 2 - Her eligibility for payments

   Choice 3 - His eligibility for payments

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

   Choice 5 - Her eligibility for the Supplemental Security Income program

   Choice 6 - His eligibility for the Supplemental Security Income program

    

5. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

6. Choice 1 - you should not have received payments

   Choice 2 - she should not have received payments

   Choice 3 - he should not have received payments

   Choice 4 - you should not have been eligible

   Choice 5 - she should not have been eligible

   Choice 6 - he should not have been eligible

    

7. Choice 1 - you qualify

   Choice 2 - she qualifies

   Choice 3 - he qualifies

    

8. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2326. Situation Where Used:

December 1973 grant amount changed.

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

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

1. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

2. Choice 1 - State of            

   Choice 2 - District of Columbia

    

2327. Situation Where Used:

December 1973 grant amount changed.

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

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

1. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

2. Choice 1 - State of            

   Choice 2 - District of Columbia

    

3. $$$.¢¢

    

2328. Situation Where Used:

December 1973 Federal arrangement changed.

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

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

1. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

2. Choice 1 - your own household

   Choice 2 - her own household

   Choice 3 - his own household

   Choice 4 - the household of your parents

   Choice 5 - the household of her parents

   Choice 6 - the household of his parents

   Choice 7 - the household of someone else

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

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

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

    

2329. Situation Where Used:

December 1973 countable income changed.

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

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

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. $$$.¢¢

    

2330. Situation Where Used:

State countable income (Vermont) changed.

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

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

1. Choice 1 - you are

   Choice 2 - she is

   Choice 3 - he is

    

2. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

3. $$$.¢¢

    

4. Choice 1 - for (Month/Year)

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

   Choice 3 - for (Month/Year) on

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

    

2331. Situation Where Used:

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

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

1. Choice 1 - Your

   Choice 2 - Her

   Choice 3 - His

    

2. $$$.¢¢

    

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

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

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

    

4. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .

    

5. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. Choice 1 - you move

   Choice 2 - she moves

   Choice 3 - he moves

    

2332. Situation Where Used:

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

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

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

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - State of       

   Choice 2 - District of Columbia

    

3. (Month/Year)

    

2333. Situation Where Used:

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

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

1. Choice 1 - you

   Choice 2 - her

   Choice 3 - him

    

2. Choice 1 - State of            

   Choice 2 - District of Columbia

    

3. (Month/Day/Year)

    

4. Choice 1 - you later decide you wish

   Choice 2 - she later decides she wishes

   Choice 3 - he later decides he wishes

    

2335. Situation Where Used:

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

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

1. Choice 1 - change was

   Choice 2 - changes were

    

2. Choice 1 - you were

   Choice 2 - she was

   Choice 3 - he was

    

2336. Situation Where Used:

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

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

1. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2. Choice 1 - monthly payment

   Choice 2 - eligibility

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2337. Situation Where Used:

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

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

1. Choice 1 - you receive

   Choice 2 - she receives

   Choice 3 - he receives

    

2. Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

3. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

2338. Situation Where Used:

Recipient loses eligibility for a State supplementary payment.

   (1)          (2)    not eligible for money     (3)           (4)          (5)   

1. Choice 1 - You

   Choice 2 - She

   Choice 3 - He

    

2. Choice 1 - are

   Choice 2 - is

   Choice 3 - were

   Choice 4 - was

    

3. Choice 1 - from your State

   Choice 2 - from her State

   Choice 3 - from his State

   Choice 4 - from the District of Columbia

    

4. Choice 1 - for (Month/Day/Year

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

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

    

5. Choice 1 - ,

   Choice 2 - and

   Choice 3 - .