INFORMATION TO BE INCLUDED ON RECONTACT QUESTIONNAIRE 



1. Current address. If different from that shown on form. 



2. Employment or self-employment (self or any person for whom receiving 



benefits) 



3. Divorce/marriage - remarriage/annulment (self or an\ person for whom 



receiving benefits) 



l*. If representative payee for incapable adult or chUd. information 



related to custody of the beneficiary and chi Id-ir-care . if applicable. 



ADDITIONAL INFORMATION FOR SSI RECIPIENTS 



1. Change in living arrangement 



2. Change In resources 



3. Change In earned or unearned Income 



Figure 3.2 



-26- 



