Aarp Foundation Web Based Scsep Application Form (Page 4 of 7) in pdf

Aarp Foundation Web Based Scsep Application Form Page 4

ARRP FOUNDATION

Web Based SCSEP Application Form

Part 1: Eligibility Determination

Other Family Member in the Household’s Name:

OTHER FAMILY MEMBER’S INCOME STATEMENT (IF APPLICABLE)

Please list the income for your family member for the last (most recent) 12 months: All cells MUST be completed. Please enter a “ 0” in each cell if

no income

Gross

Military

Earnings

401(k) Draw,

Monthly

Railroad

Fed/State/Local

Pension

Other

Month / Year

Annuities

Dividends or

Other Income

Social

Pension

Gov’t Pension

(Non-

Pensions

Wages

Interest

Security

Disability)

If your other family member received Social Security in the last 12 months, what type of Social

Security was it?

_____Retirement Social Security

_____Social Security Disability

_____Supplemental Security Income

***IMPORTANT: For each type of income listed above, you must provide financial documentation

validating that amounts that you listed in the cells above.

***IMPORTANT: Please include photocopies of financial documentation for each type of income for

family member. Refer to the Supporting Documentation Summary Page for details.

Revised: 9/21/2011

Aarp Foundation Web Based Scsep Application Form Page 4