| Social Security Administration |
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Form Approved OMB No. 0960-0421 |
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| STATE AGENCY REPORT OF OBLIGATIONS FOR SSA DISABILITY PROGRAMS |
| (See instructions for completing form on reverse) |
| NAME OF AGENCY |
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STATE |
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| FISCAL YEAR |
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FOR PERIOD |
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From: |
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To: |
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(A) |
(B) |
(C) |
| REPORTING ITEMS - ALL TITLES |
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DISBURSEMENTS |
UNLIQUIDATED |
TOTAL |
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OBLIGATIONS |
OBLIGATIONS |
| 1. Personnel Service Costs |
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0 |
| 2. Medical Costs |
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(sum of 2a+2b) |
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0 |
0 |
0 |
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a. |
Consultative Examinations |
(sum of a1+a2+a3) |
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0 |
0 |
0 |
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1) Disability Insurance (DI) Claims |
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0 |
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2) Supplemental Security Income (SSI) Claims |
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0 |
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3) Concurrent DI/SSI Claims |
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0 |
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b. |
Medical Evidence of Record |
(sum of b1+b2+b3) |
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0 |
0 |
0 |
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1) Disability Insurance (DI) Claims |
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0 |
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2) Supplemental Security Income (SSI) Claims |
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0 |
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3) Concurrent DI/SSI Claims |
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0 |
| 3. Indirect Costs |
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[see attached addendum] |
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0 |
| 4. All Other Nonpersonnel Costs |
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0 |
0 |
0 |
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a. |
Occupancy |
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0 |
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b. |
Contracted Costs (exclude EDP) |
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0 |
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c. |
EDP Maintenance |
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0 |
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d. |
New EDP Equipment/Upgrades |
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0 |
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e. |
Equipment Total |
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0 |
0 |
0 |
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1) Purchases |
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0 |
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2) Rental |
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0 |
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f. |
Communications |
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0 |
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g. |
Applicant Travel |
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0 |
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h. |
DDS Travel |
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0 |
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i. |
Supplies |
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0 |
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j. |
Miscellaneous |
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0 |
| 5. Total: |
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(sum of 1 thru 4) |
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0 |
0 |
0 |
| 6. Cumulative Obligational Authorization |
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| 7. SSA-871 Attached? |
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YES |
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NO |
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| I CERTIFY THAT THE ABOVE REPORT AND ANY SUPPORTING STATEMENTS ARE TRUE |
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| STATEMENTS OF DISBURSEMENTS AND UNLIQUIDATED OBLIGATIONS FOR DETERMINATIONS |
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| OF DISABILITY UNDER THE PROVISIONS OF THE SOCIAL SECURITY ACT, AS AMENDED. |
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| SIGNATURE |
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TITLE |
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DATE |
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| Form SSA-4513 (6-2001) |
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| Destroy All Prior Editions |
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