The following questions pertain to all months since the last review of SSI eligibility:

1. Have you changed your State of residence from California at any time since we last reviewed your case?

   • Yes _______ No ________

   • If yes, when did you change your State of residence? _______________

2. Have you married at any time since we last reviewed your case,

   • Yes _______ No ________

   • If yes, what is your spouse’s name and social security number?

3. If yes to question 2, has your spouse ever received SSI or payments under a State aid plan (AB, ATD, OAS, or AFDC/TANF?

   • Yes ________ No ________

   • If no:

     • (a) Have you had any minor children living with you and your spouse at any time since we last reviewed your case?

       Yes ________ No ________

       If yes, list the names, dates of birth, and income (if any) of the children:

     • (b) Do you pay for any medical needs of your children or spouse?

       Yes ________ No ________

       If yes” what are your children’s and spouse’s medical needs:

       _____________________________ $ ____________________

     • (c) Did your spouse incur any debts to provide family needs before you received assistance:

       Yes ________ No ________

       If yes, how much? $ ______________

     • (d) Did your spouse pay for such things as major house repair or replacement of furniture?

       Yes ________ No ________

       If yes, how much? $ ______________

4. Have you worked or engaged in self-employment at any time since we last reviewed your case?

   Yes ________ No ________

   Has your spouse?

   Yes ________ No ________

   If yes, what are your (your spouse’s) work expenses?

      Taxes, retirement $ ____________

      Transportation    $ ____________

      Insurance             $ ____________

      Meals             $ ____________

      Child care         $ ____________

      Other             $ ____________

5. Do you live in your own home, apartment, etc.? Yes _______ No _______

   If yes:

   How much is the rent or mortgage? ____________

   Do others live with you? Yes ________ No ________

   How many people are in the household? ___________

6. Do you live with someone and pay them for room and board? Yes ____ No ____

   If yes, how much do you pay per month? $ _________

7. Do you live in a nonmedical board and care facility? Yes ______ No _______

8. Do you live in a medical facility or intermediate care facility? Yes ____ No ____

9. Does anyone else pay any of the following expenses for you?

   Food         Yes ____ No ____

   Clothing     Yes ____ No ____

   Rent         Yes ____ No ____

   Transportation Yes ____ No ____

   Utilities     Yes ____ No ____

10. Did you receive a nonrecurring lump sum payment such as a title II, worker’s compensation, or pension payment? Yes _______ No _______

    If yes, when? ____________

    How much $ ____________

11. Did you receive a tax refund? Yes _______ No _______

    If yes, when? Yes _______ No _______

    How much? ______________

12. Do you pay someone to provide domestic or personal care services in your own home? Yes _______ No _______

    If yes, how much? $ _____________