Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 7
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10SFN 958 (4-2017)
Page 7 of 10
Unearned Income or Other Money Received
The following is a list of different kinds of unearned income. Check yes for each unearned income or other money received by household
members. Check no, if not received.
Yes
No
Benefits while on Strike
Yes
No
Money from Friends, Relatives or Others
Yes
No
BIA/Tribal General Assistance**
Yes
No
Money from Inheritance
Yes
No
Bingo/Gambling Winnings
Yes
No
Oil/Mineral Rights/Royalties
Yes
No
Child Support** or Spousal Support
Yes
No
Pension/Retirement Benefits
Yes
No
Contract Sale or Rental Income
Yes
No
Railroad Retirement Benefits
Yes
No
Income from CRP
Yes
No
Refugee Assistance
Yes
No
Income from Tribes
Yes
No
Social Security Benefits
Yes
No
Yes
No
Income from Roomer/Boarder
Supplemental Security Income (SSI)
Yes
No
Yes
No
Individual Indian Monies (IIM)
TANF-Temporary Assistance for Needy Families
Yes
No
Yes
No
Insurance/Lawsuit Settlement
Unemployment Benefits
Yes
No
Yes
No
Interest/Dividend Income
Veteran's/Military Benefits
Yes
No
Money Deposited into a Bank Account from
Workers' Compensation
Yes
No
an Individual Outside of Your Household
Other, specify:
For all items checked yes, fill in the information below:
Type of Unearned Income or
How Often
Amount This
Amount
Household Member
Other Money Received
Received
Month
Next Month
Have household members applied for benefits not yet received (Social Security, SSI,
Yes
No
If yes, explain:
Worker's Compensation, Unemployment Compensation, Veterans/Military Benefits?)
Tell Us About Your Household Assets
Tell Us About Your Household Assets
List household members who have made arrangements for funeral expenses or gave money, property, or insurance to someone else to
pay for funeral expenses:
Explain:
Do you expect changes in assets next month?
If yes, explain:
Yes
No
Transfer of Assets
Have household members sold, given away or transferred anything of value within the past 5 years?
Yes
No
If yes, list the items:
Date
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