Questionnaire Text

Questionnaire form view entire document:  text  image
e) Supplemental Security Income (SSI)
[ ] Yes -->$_____________________.00 (TOTAL AMOUNT for past 12 MONTHS)
[ ] No
Questionnaire instructions view entire document:  text  image
Mark the "Yes" or "No" box for each type of income, and enter the amount received IN THE PAST 12 MONTHS for each "Yes" response.

If income from any source was received jointly by household members, report, if possible, the appropriate share for each person; otherwise, report the whole amount for only one person and mark the "No" box for the other person.

When reporting income received jointly, DO NOT include the amount for a person not listed on pages 2, 3, or 4.

47e. Include Supplemental Security Income (SSI) received by elderly, blind, or disabled persons.