Part 4: Means-Tested Benefits

If you selected Item Number 1.A. in Part 1, complete this section.

1. If you, your spouse, or the head of household (including parent if the child is under 21 years of age) living with you is receiving any means-tested benefits, list the information below and attach supporting documentation. If you are the parent or legal guardian filing on behalf of a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this form if they are receiving a means-tested benefit.

Means-Tested Benefit Recipients

Enter at least one benefit recipient. Leave unused rows blank.

Enter the expiration or renewal date when applicable. If the benefit has no expiration or renewal date, explain in Additional information below.

Benefit recipient 1
Benefit recipient 2 (if included)
Benefit recipient 3 (if included)
Benefit recipient 4 (if included)
Benefit recipient 5 (if included)
Benefit recipient 6 (if included)
Benefit recipient 7 (if included)
Benefit recipient 8 (if included)
For each additional entry, include the recipient's full name, relationship to you, agency, benefit type, award date, and expiration or renewal date. Identify the recipient when adding an explanation. This information will go in Part 10 of the PDF.
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