Form DCSS0046 "Supplemental Security Income (Ssi) Resource Test Self-certification" - California

Form DCSS0046 or the "Supplemental Security Income (ssi) Resource Test Self-certification" is a form issued by the California Department of Child Support Services.

The form was last revised in August 22, 2005 and is available for digital filing. Download an up-to-date Form DCSS0046 in PDF-format down below or look it up on the California Department of Child Support Services Forms website.

ADVERTISEMENT

Download Form DCSS0046 "Supplemental Security Income (Ssi) Resource Test Self-certification" - California

877 times
Rate
(4.6 / 5) 61 votes
DEPARTMENT OF CHILD SUPPORT SERVICES
STATE OF CALIFORNIA - HEALTH INSURANCE SERVICES
SUPPLEMENTAL SECURITY INCOME (SSI) RESOURCE TEST
SELF-CERTIFICATION
DCSS 0046 (08/22/05)
If you receive monthly Social Security Disability Insurance (SSDI) benefits and you have
limited resources, you may qualify to have only 5% of your SSDI benefits attached for
payment toward your past-due child support (arrearage) balance. This SSI resource test
will be used to determine if you qualify and/or modify the support order.
NAME
(Last)
(First)
(Middle Initial)
MAILING ADDRESS
CITY
COUNTY
STATE
ZIP CODE
PARTICIPANT IDENTIFICATION NUMBER
CHILD SUPPORT CASE NUMBER
Resources:
Things you own such as cash, bank accounts, land, life insurance, and personal property.
Resources that DO NOT COUNT when deciding if you meet the SSI resource limit:
The home you live in and the land it is on
Household goods and personal property that are not worth more than $2,000
One wedding ring and one engagement ring
The value of one automobile
Burial spaces for you and your spouse
Burial funds up to $1,500
Life insurance worth $1,500 or less
Resources such as wheelchairs, respirators, care services, etc.
I do not have resources worth more than:
(Please check one.)
$2,000 for one person
$3,000 for a couple
My monthly SSDI benefit amount is $
.00.
(Please attach a copy of your last SSDI benefit payment or payment stub.)
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct.
DATE
SIGNATURE
DEPARTMENT OF CHILD SUPPORT SERVICES
STATE OF CALIFORNIA - HEALTH INSURANCE SERVICES
SUPPLEMENTAL SECURITY INCOME (SSI) RESOURCE TEST
SELF-CERTIFICATION
DCSS 0046 (08/22/05)
If you receive monthly Social Security Disability Insurance (SSDI) benefits and you have
limited resources, you may qualify to have only 5% of your SSDI benefits attached for
payment toward your past-due child support (arrearage) balance. This SSI resource test
will be used to determine if you qualify and/or modify the support order.
NAME
(Last)
(First)
(Middle Initial)
MAILING ADDRESS
CITY
COUNTY
STATE
ZIP CODE
PARTICIPANT IDENTIFICATION NUMBER
CHILD SUPPORT CASE NUMBER
Resources:
Things you own such as cash, bank accounts, land, life insurance, and personal property.
Resources that DO NOT COUNT when deciding if you meet the SSI resource limit:
The home you live in and the land it is on
Household goods and personal property that are not worth more than $2,000
One wedding ring and one engagement ring
The value of one automobile
Burial spaces for you and your spouse
Burial funds up to $1,500
Life insurance worth $1,500 or less
Resources such as wheelchairs, respirators, care services, etc.
I do not have resources worth more than:
(Please check one.)
$2,000 for one person
$3,000 for a couple
My monthly SSDI benefit amount is $
.00.
(Please attach a copy of your last SSDI benefit payment or payment stub.)
I declare under penalty of perjury under the laws of the State of California that the foregoing
is true and correct.
DATE
SIGNATURE
ADVERTISEMENT