Statement of Living Arrangements, In-Kind Support and Maintenance

MSSICS SCREEN PRINTS for SSA 8006

Statement of Living Arrangements, In-Kind Support and Maintenance

OMB: 0960-0174

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MSSICS SCREEN PRINTS FOR

OMB # 0960-0174

SSA-8006-F4

The following are screen prints from the Modernized SSI Claim System (MSSICS) that collect information that is equivalent to the paper form SSA-8006-F4. Like the SSA-8006-F4, these MSSICS screens collect information that is needed to establish whether the SSI beneficiary lives in his or her own household or lives in another person’s household. Like the SSA-8006-F4, these screens also collect information that is needed to determine if the SSI beneficiary receives in-kind support and maintenance from inside the household, from outside the household, or does not receive any in-kind support and maintenance.

LXHP Screens (Householder In-Kind Support and Maintenance/Cash Income)

The LXHP screens collect information to determine in-kind support and maintenance when an SSI beneficiary is considered to be living in his or her own household and has roommates who contribute to paying the household’s expenses.

LOHH Screens (In-Kind Support and Maintenance Provided in the Household of Another)

The LOHH screens collect information to determine in-kind support and maintenance when an SSI beneficiary lives in the household of another and may be receiving food and shelter paid for by the other members of the household.

LISM Screens (In-Kind Support and Maintenance Received from Outside the Household)

The LISM screens collect information to determine whether the SSI beneficiary is getting in-kind support and maintenance because the beneficiary gets food or shelter provided by third parties outside the household.

MSSICS HOUSEHOLDER ISM/CASH DATA PAGE 1 OF LXHP

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[3-M]

DO OTHERS CONTRIBUTE TO HOUSEHOLD EXPENSES (Y/N): X

[4-C]

EAT ALL MEALS OUT(Y/N): X

[5-C]

IF NO, BUY FOOD SEPARATE FROM HOUSEHOLD (Y/N): X

[6-C] [7-C]

CONTRIBUTION AVERAGE PERIOD FROM (MMYY): PPPP TO (MMYY): PPPP

[8-C]

AMOUNT OTHERS CONTRIBUTE: 9999999

[9-C]

MONTHLY LOAN AMOUNT: 9999999

[10-C]

AMOUNT CLAIMANT CONTRIBUTES: 9999999 [11-O]

REMARKS (Y): X

MSSICS HOUSEHOLDER ISM/CASH DATA PAGE 2 OF LXHP

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[12-M] [13-M]

EXPENSE AVERAGE PERIOD FROM (MMYY): PPPP TO (MMYY): PPPP

FOR THE PERIOD ABOVE, COLLECT THE FOLLOWING MONTHLY EXPENSES

[14-M] [15-M]

FOOD: 9999999 MORTGAGE/RENT: PPPPPPP

[16-C] [17-C]

PROPERTY INSURANCE: 9999999 PROPERTY TAXES: 9999999

[18-M] [19-M]

HEATING FUEL: 9999999 ELECTRICITY: 9999999

[20-M] [21-M]

GAS: 9999999 GARBAGE REMOVAL: 9999999

[22-M] [23-M]

WATER: 9999999 SEWER: 9999999

[24-D]

TOTAL EXPENSES: SSSSSSS

[25-D]

PRO RATA SHARE: SSSSSSS

[11-O]

REMARKS (Y): X

MSSICS HOUSEHOLDER ISM/CASH DATA PAGE 3 OF LXHP

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[26-D] [27-M] [28-D] [29-D]

DEEMOR AMOUNT DEEMOR EXCESS FROM CLAIMANT'S

CONTRIBUTES: DEEMOR SHARE

SSSSS SSSSSSSSS 9999999 SSSSSSS SSSSSSS

[30-D] [31-D]

TOTAL FOR CLAIMANT: SSSSSSSS CLAIMANT'S EXCESS: SSSS.SS

[32-D] [33-D]

INSIDE ISM TO CLAIMANT: SSSSSSS CASH FROM WITHIN THE HOUSEHOLD: SSSSSSS

[34-C]

CONTRIBUTION VERIFICATION REQUIRED - RECEIVED(Y/N): X [11-O]

REMARKS (Y): X

MSSICS HOUSEHOLD OF ANOTHER PAGE 1 OF LOHH

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[3-M]

EAT ALL MEALS OUT (Y/N): X

[4-C]

IF NO, BUY FOOD SEPARATE FROM HOUSEHOLD (Y/N): X

[5-C]

WISH TO REBUT PMV (Y/N): X

[6-C]

CLAIMANT/DEEMOR CONTRIBUTE TOWARD HOUSEHOLD EXPENSES (Y/N): X

[7-C]

CLAIMANT MAKES TOKEN CONTRIBUTION (Y/N): X

[8-C]

DEEMOR MAKES TOKEN CONTRIBUTION (Y/N): X

[9-C] [10-C]

CONTRIBUTION AVERAGE PERIOD FROM (MMYY): PPPP TO (MMYY): PPPP

[11-C]

MONTHLY LOAN AMOUNT: 9999999

[12-C]

CLAIMANT'S CONTRIBUTION: 9999999

MSSICS HOUSEHOLD OF ANOTHER PAGE 2 OF LOHH

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[14-M] [15-M]

EXPENSE AVERAGE PERIOD FROM (MMYY): PPPP TO (MMYY): PPPP

FOR THE PERIOD SHOWN, COLLECT THE FOLLOWING MONTHLY EXPENSES

[16-C] [17-M]

FOOD: 9999999 MORTGAGE/RENT: PPPPPPP

[18-C] [19-C]

PROPERTY INSURANCE: 9999999 PROPERTY TAXES: 9999999

[20-M] [21-M]

HEATING FUEL: 9999999 ELECTRICITY: 9999999

[22-M] [23-M]

GAS: 9999999 GARBAGE REMOVAL: 9999999

[24-M] [25-M]

WATER: 9999999 SEWER: 9999999

[26-D]

TOTAL EXPENSES: SSSSSSS

[27-D]

PRO RATA SHARE: SSSSSSS

[28-C]

CONTRIBUTION VERIFIED (Y/N): Y

[13-O]

REMARKS (Y): X

MSSICS HOUSEHOLD OF ANOTHER PAGE 3 OF LOHH

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

EARMARK OPTIONS 1=NOT EARMARKED 2=FOOD 3=SHELTER 4=BOTH FOOD SHELTER

[29-D] [30-M] [31-M] [32-D] [33-D]

DEEMOR CONTRIBUTION: EARMARKED EXCESS FROM CLAIMANT'S

DEEMOR SHARE

SSSSS SSSSSSSSS 9999999 9 SSSSSSS SSSSSSS

[34-D]

TOTAL FOR CLAIMANT: SSSSSSS

[13-O]

REMARKS (Y): X

MSSICS HOUSEHOLD OF ANOTHER PAGE OF LOHH

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[34-D]

TOTAL FOR CLAIMANT: SSSSSSS

[35-M]

CLAIMANT'S CONTRIBUTION EARMARKED FOR: 9 1=NOT EARMARKED

2=FOOD ONLY

3=SHELTER ONLY

4=BOTH FOOD SHELTER

[36-C] [37-C]

IF 4, FOOD AMOUNT: 9999999 SHELTER AMOUNT: 9999999

[38-D] [39-D]

FOOD SHARE: SSSSSSS SHELTER SHARE: SSSSSSS

[40-D]

TOTAL ISM FROM HOUSEHOLD: SSSSSSS

[41-C]

EARMARKED CONTRIBUTION VERIFIED (Y/N): X

[13-O]

REMARKS (Y): X

VERSION 1

MSSICS ISM PAGE 1 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[3-M]

PERSON RECEIVING ISM: 9 1=SSSSS SSSSSSSSS

2=SSSSS SSSSSSSSS

3=BOTH EQUALLY

[4-M]

SOURCE NAME: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[6-C] [7-C]

ISM COUNTABLE (Y/N): P IF NO, REASON:

[8-C] XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

TYPE OF ISM: P 1=FOOD

2=SHELTER

3=CLOTHING/ISM TO ONE

4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

[10-O] [11-O] [12-O]

ANOTHER SOURCE (Y): X DELETE THIS SOURCE (Y): X REMARKS (Y): X

VERSION 2

MSSICS ISM PAGE 1 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[13-M]

DOES ISM HAVE VALUE (Y/N): X

[14-M]

IF TRANSIENT, WISH TO REBUT PMV (Y/N): X

[4-M]

SOURCE NAME: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[6-C] [7-C]

ISM COUNTABLE (Y/N): P IF NO, REASON:

[8-C] XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

TYPE OF ISM: P 1=FOOD

2=SHELTER

3=CLOTHING/ISM TO ONE

4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

[10-O] [11-O] [12-O]

ANOTHER SOURCE (Y): X DELETE THIS SOURCE (Y): X REMARKS (Y): X

VERSION 3

MSSICS ISM PAGE 1 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[4-M]

SOURCE NAME: PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

[5-M]

SOURCE ADDRESS: PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

PPPPPPPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPP

[6-C] [7-C]

ISM COUNTABLE (Y/N): P IF NO, REASON: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

[8-C]

TYPE OF ISM: P 1=FOOD

2=SHELTER

3=CLOTHING/ISM TO ONE

4=FOOD/SHELTER (NOT HOUSEHOLD SITUATIONS)

[9-C]

NUMBER WHO SHARE FOOD: 99

[10-O] [11-O] [12-O]

ANOTHER SOURCE (Y): X DELETE THIS SOURCE (Y): X REMARKS (Y): X

VERSION 1

MSSICS ISM PAGE 2 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

SHELTER EXPENSE TYPE

[15-O] [16-O]

RENT FREE HOUSING: 9999999 PROPERTY TAXES: 9999999

[17-O] [18-O]

MORTGAGE/RENT: 9999999 ELECTRICITY: 9999999

[19-O] [20-O]

HEATING FUEL: 9999999 GARBAGE REMOVAL: 9999999

[21-O] [22-O]

WATER: 9999999 SEWER: 9999999

[23-O] [24-O]

GAS: 9999999 RENTAL SUBSIDY: PPPPPPP

[25-C] [26-O]

PROPERTY INS: 9999999 MULTIPLE SHELTER ITEMS: 9999999

[27-D]

TOTAL EXPENSES: SSSSSSSS

[28-M]

MONTHLY VALUE: PPPPPPP

[29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N): X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS: SSSSSSS

[10-O] [12-O]

ANOTHER SOURCE (Y/N): X REMARKS (Y): X

VERSION 2

MSSICS ISM PAGE 2 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

SHELTER EXPENSE TYPE

[15-O] [16-O]

RENT FREE HOUSING: 9999999 PROPERTY TAXES: 9999999

[17-O] [18-O]

MORTGAGE/RENT: 9999999 ELECTRICITY: 9999999

[19-O] [20-O]

HEATING FUEL: 9999999 GARBAGE REMOVAL: 9999999

[21-O] [22-O]

WATER: 9999999 SEWER: 9999999

[23-O] [24-O]

GAS: 9999999 RENTAL SUBSIDY: PPPPPPP

[25-O] [26-O]

PROPERTY INS: 9999999 MULTIPLE SHELTER ITEMS: 9999999

[27-D]

TOTAL EXPENSES: SSSSSSSS

[28-M]

MONTHLY VALUE: PPPPPPP

[29-C]

ARE PAYMENTS FROM ABSENT PARENT (Y/N): X

[30-D]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS: SSSSSSS

[10-O] [12-O]

ANOTHER SOURCE (Y/N): X REMARKS (Y): X

VERSION 3

MSSICS ISM PAGE 2 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[28-M]

MONTHLY VALUE: PPPPPPP

[29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N): X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS: SSSSSSS

[10-O] [12-O]

ANOTHER SOURCE (Y/N): X REMARKS (Y): X

VERSION 4

MSSICS ISM PAGE 2 OF LISM

[1-D] [2-O]

SSS-SS-SSSS SSSSS SSSSSSSSSS PERIOD BEGAN: SS/SS/SSSS TRANSFER TO: XXXX

[28-M]

MONTHLY VALUE: PPPPPPP

[29-D]

ARE PAYMENTS FROM ABSENT PARENT (Y/N): X

[30-C]

CLAIMANT'S SHARE OF ISM: SSSSS SSSSSSSSS: SSSSSSS

[10-O] [12-O]

ANOTHER SOURCE (Y/N): X REMARKS (Y): X

File Type	application/msword
Author	497351
Last Modified By	889123
File Modified	2011-12-06
File Created	2011-12-06