FACSIMILE: AHOD - HOLDING OUT DATA
MSSICS HOLDING OUT DATA AHOD
SSS-SS-SSSS SSSSS SSSSSSSSSS TRANSFER TO: XXXX
OTHER PERSON'S NAME: VVVVVVVVVVVVVVV VVVVVVVVVVVVVVV VVVVVVVVVVVVVVVVVVVV VVVV
OTHER PERSON'S SSN: VVVVVVVVV
ALLEGE HOLDING OUT AS COUPLE TO COMMUNITY (Y/N): X
DEVELOPMENT NEEDED (Y): X
IF YES,
NAME YOU ARE KNOWN BY TO COMMUNITY: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
HOW YOU INTRODUCE THE OTHER PERSON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
HOW MAIL IS ADDRESSED TO YOU : XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
BILLS ADDRESSED AS HUSBAND AND WIFE (Y/N): X
RESIDENCE OWNED OR RENTED BY BOTH (Y/N): X
IF YES, NAME ON DEED OR LEASE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CONSIDER AS A COUPLE FOR SSI (Y/N): B VERIFIED (Y/N): X
IF NO, EXPLAIN: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
IF YES, HOLDING OUT BEGIN DATE (MMDDCCYY): PPPPPPPP
END DATE (MMDDCCYY): PPPPPPPP
ANOTHER RELATIONSHIP (Y): X DELETE THIS SOURCE (Y): X REMARKS (Y): X
| File Type | application/msword |
| Author | 283180 |
| Last Modified By | 889123 |
| File Modified | 2014-07-16 |
| File Created | 2014-07-16 |