Page 13

RECORD POSITION FIELD NAME FIELD SIZE &TYPE DESCRIPTION Name 125-139 Spouse’s Middle Name PIC X(15) Spouse’s Middle Name 140-161 Spouse’s Last Name PIC X(22) Spouse’s Last Name 162-165 Spouse’s Suffix PIC X(04) Spouse’s Suffix 166-173 Spouse’s Date of Birth PIC 9(08) This is the spouse’s date of birth provided in the format of a two-digit month a two-digit day and a four-digit year. Format: MMDDCCYY 174-177 Spouse’s Burial/Funeral Expenses PIC 9(04) Question 5 on the SSA LIS application asks if some money will be used for burial expenses. If the beneficiary checks no, a zero will be shown here. If “no” was not checked on question 5, SSA allowed the $1,500 burial expense exclusion when counting the resources and $1,500 will be displayed in this field. Values: 0 or 1500 178-199 Mailing Address (8 Lines)

Note: SSA uses the address on record, unless the beneficiary indicates on page 6 of the LIS application that his/her address changed within the past three months. Then the address is taken off the application. PIC X(22) 1st Line of Address 200-221 PIC X(22) 2nd Line of Address 222-243 PIC X(22) 3rd Line of Address 244-265 PIC X(22) 4th Line of Address 266-287 PIC X(22) City 288-289 PIC X(02) State 290-294 PIC X(05) ZIP+5 295-298 PIC X(04) ZIP+4 299-313 Phone PIC X(15) This is the telephone number on SSA records. 314 Subsidy Approved PIC X(01) This field indicates whether the beneficiary or beneficiary and spouse have been approved for Extra Help. Values: Y = Yes (Award) and N = No (Denied) 315-322 Subsidy Approval/ Disapproval Date PIC 9(08) This is the date the determination was made to approve or disapprove the application for Extra Help. Format: MMDDCCYY