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METRO PAYEE SERVICES INC. P 0 Box 270190 St Paul MN 55127 651 407-0526 Fax 651 653-3227 CONTINUING DISABILITY UPDATE REPORT Periodically Social Security conducts Disability Update Reviews to confirm your continuing disability eligibility. Some of the information they require can only be provided by the client. Please complete the following information and return this form to our office. If at any time during a review we are unable to satisfactorily answer their questions they will place a hold on your benefits until the information is provided* Therefore in an effort to help avoid any potential benefit delays we are now gathering information for your file. This information is considered private and will not be shared with any other sources. YIN Resource Resource Value Additional Info Stocks/Bonds Value Certificates of Deposit Mutual Funds Burial Funds/Policy Annuity/IRA Savings Account Balance Bank Name Checking Account Cash on hand Property/Real Estate Location CarsNehicles Make/Model/YearNalue Rental Properties Income Married Single Widowed Not married but living as a mutually declared married couple SSI recipients only Been out of the state or country for more than one calendar month Been in a hospital/treatment facility/correctional facility for more than one calendar month smce 2012 Date Income from any other source other than county Value/Source MSA EBT Food Stamps MFIP child/ren s name Energy Assistance Vendor Telephone Assistance List any dependent children/dates of birth living with you Please use the back of this form for this information DOB CLIENT S NAME SS ADDRESS CITY PHONE MN CASE MANAGER COUNTY FINANCIAL WORKER WORKING EMPLOYER Y N- Mthly Gross Wages YOUR BIRTHPLACE City/St ZIP COUNTY AFFILIATE Hourly wage AVG WKLY HOURS CITY/ZIP MOTHER S MAIDEN NAME SIGNATURE DATE Thank you for your cooperation in completing this form* Please advise immediately if any information changes. Some of the information they require can only be provided by the client. Please complete the following information and return this form to our office. If at any time during a review we are unable to satisfactorily answer their questions they will place a hold on your benefits until the information is provided* Therefore in an effort to help avoid any potential benefit delays we are now gathering information for your file. If at any time during a review we are unable to satisfactorily answer their questions they will place a hold on your benefits until the information is provided* Therefore in an effort to help avoid any potential benefit delays we are now gathering information for your file. This information is considered private and will not be shared with any other sources. YIN Resource Resource Value Additional Info Stocks/Bonds Value Certificates of Deposit Mutual Funds Burial Funds/Policy Annuity/IRA Savings Account Balance Bank Name Checking Account Cash on hand Property/Real Estate Location CarsNehicles Make/Model/YearNalue Rental Properties Income Married Single Widowed Not married but living as a mutually declared married couple SSI recipients only Been out of the state or country for more than one calendar month Been in a hospital/treatment facility/correctional facility for more than one calendar month smce 2012 Date Income from any other source other than county Value/Source MSA EBT Food Stamps MFIP child/ren s name Energy Assistance Vendor Telephone Assistance List any dependent children/dates of birth living with you Please use the back of this form for this information DOB CLIENT S NAME SS ADDRESS CITY PHONE MN CASE MANAGER COUNTY FINANCIAL WORKER WORKING EMPLOYER Y N- Mthly Gross Wages YOUR BIRTHPLACE City/St ZIP COUNTY AFFILIATE Hourly wage AVG WKLY HOURS CITY/ZIP MOTHER S MAIDEN NAME SIGNATURE DATE Thank you for your cooperation in completing this form* Please advise immediately if any information changes..

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