Has the client received any income from any source over the last 30 days? No Client does not know Yes Client refused [IF YES] Complete the following: Receiving income from Amount from source (round to Source of income source? nearest dollar) No Earned income (i.e., employment income) $ .00 Yes No Unemployment Insurance $ .00 Yes No Supplemental Security Income (SSI) $ .00 Yes No Social Security Disability Income (SSDI) $ .00 Yes No Veteran’s disability payment $ .00 Yes No Private disability insurance $ .00 Yes No Worker’s compensation $ .00 Yes No Temporary Assistance for Families (TANF) $ .00 Yes General Assistance (GA) No
Has the client received any income from any source over the last 30 days? No Client does not know Yes Client refused [IF YES] Complete the following: Source of income Receiving income from source? Amount from source (round to nearest dollar) Earned income (i.e., employment income) No $ .00 Yes Unemployment Insurance No $ .00 Yes Supplemental Security Income (SSI) No $ .00 Yes Social Security Disability Income (SSDI) No $ .00 Yes Veteran’s disability payment No $ .00 Yes Private disability insurance No $ .00 Yes Worker’s compensation No $ .00 Yes Temporary Assistance for Families (TANF) No $ .00 Yes General Assistance (GA) No
VA_Data_Guide4_14.docx