ࡱ> -/,{ bjbjzz 5  $*****$VZ**kkk **kkkk*`g=Fk0$kUkk$kk$ :  AFFIDAVIT IN THE MATTER OF THE APPLICATION OF ________________ SS# ____________ FOR SUPPLEMENTAL SECURITY INCOME BENEFITS --------------------------------------------- STATE OF ___________: COUNTY OF ______ : SS CITY OF ___________ : I, (NON DISABLED ADULT) being duly sworn, deposes and says: 1. I reside at ____________________________________. 2. I provide room and lodging for my adult disabled (RELATIONSHIP), (NAME OF DISABLED ADULT), at the above address each month for a flat fee pursuant to an oral business agreement. 3. I charge (NAME OF DISABLED ADULT) $_____ per month for room and lodging pursuant to that oral agreement. 4. I would charge the same amount, $_____ per month for any nonrelatives who I took in as a roomer-lodgers under a similar business arrangement. 5. (NAME OF DISABLED ADULT) has no equity or property interest in my home. 6. (NAME OF DISABLED ADULT) does not share in the insurance, maintenance, repair, furnishing, decorating, utilities, or any other operational cost of my home. 7. (NAME OF DISABLED ADULT) does not participate in any decisions regarding home repairs, improvements, or other aspects of daily activities. 8. We do not "pool" our funds for any household expenses. 9. (NAME OF DISABLED ADULT) does not contribute to, nor does his name appear on any bills as a responsible party for my actual expenses of operating the house on a per expense or pro-rata basis because he is a roomer-lodger in my home. 10. I understand that it is the policy of the Social Security Administration that when a recipient of Supplemental Security Income benefits (SSI) resides with others, household expenses must be apportioned and that a recipient must pay a pro-rata share of these costs in order to receive the regulated amount of SSI benefits. 11. However, as of (DATE ARRANGEMENT BEGAN), following our agreement, (NAME OF DISABLED ADULT) is now paying a flat fee of $______ a month for room and lodgings. Since I, myself, am not in receipt of any Social Security benefits, I am unwilling to apportion my household expenses according to Social Security policy. 12. If (DISABLED ADULT) is unable to pay the flat fee for rent for his room and lodging, I will make him leave. 13. I do not contribute in any ways to the needs of (DISABLED ADULT). _____________________________ Affiant Sworn to before me this ____ day of _________, 20__. ______________________________ Notary Public h3Vh34EVW1 2 3 h i  0^`0$a$$a$i " # ' ( v w   \] 0^`0 `^``?UVWXu `^``3...()()()..)() 0P/ =!"#$% 8$Dpf 666666666vvvvvvvvv666666>66666666666666666666666666666266666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~OJQJ_HmH nH sH tH P`P Normal1$7$8$H$OJQJ^J_HmH sH tH DA D 0Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  i  8@0(  B S  ? &u x 33333 z>3V @ @UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@ CalibriOCourier 10cpiTimesA$BCambria Math"hڱņtMtMAxx2 3$Pz>2!xx ~DRAFT AFFIDAVIT # 2 (To be used to prove disabled adult should not be treated as living with others or within the household ofNeighborhood Legalhireyou2Oh+'0 ,HTd x    DRAFT AFFIDAVIT # 2 (To be used to prove disabled adult should not be treated as living with others or within the household ofNeighborhood LegalNormal hireyou23Microsoft Office Word@G@.#f=@D0@.#f=tM՜.+,0p hp  O Cornell ILR  DRAFT AFFIDAVIT # 2 (To be used to prove disabled adult should not be treated as living with others or within the household of Title  !"#%&'()*+.Root Entry Fg=01TableWordDocument5SummaryInformation(DocumentSummaryInformation8$CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q