Form 207

(f) Is your disability the result of an automobile accident, an accident at work, an accident at home

or otherwise? Please give the date and details of the incident and state whether you have filed a

lawsuit or workers’ compensation claim as a result.

(g) Have you had any children since the incident? If so, list their dates of birth.

(7) Have you applied for Social Security Disability (SSD) or Supplemental Security Income (SSI)?

(a) If you did, when did you apply and where are you in the application process?

(b) Have you been told if or when you will receive benefits? If so, who told you and what is the date

they gave you?

(c) If your application for SSD and/or SSI has been denied, did you appeal? If you appealed, what

is the status of the appeal and what lawyer, if any, represents you?

(d) Have you applied for or are you receiving state assistance?

(e) Are you a recipient of the state supplement program, medical assistance program, temporary

family assistance program or state-administered general assistance program (SAGA medical or cash)?

If so, state the source of the benefit, the effective date of the benefit and the date when your eligibility

for benefits will be redetermined by the Department of Social Services.

(8) Do you have any lawsuits pending?

(a) If you do, what type of case is it?

(b) Give the name, address, email address and phone number of the lawyer handling the case for you.

(c) What amount do you expect to recover and when do you expect to receive it?

(d) If you have already settled the case, please provide a copy of the settlement statement.

(9) Do you expect to inherit any money or property in the next six months?

(a) If you do, who do you expect to inherit from and where do they or where did they live?

(b) What do you expect to inherit, what is its value and when do you expect to inherit it?

t to recover and when do you expect to receive it?

(d) If you have already settled the case, please provide a copy of the settlement statement.

(9) Do you expect to inherit any money or property in the next six months?

(a) If you do, who do you expect to inherit from and where do they or where did they live?

(b) What do you expect to inherit, what is its value and when do you expect to inherit it?

(c) What is the name and address of the person or lawyer handling the estate and where is the

Probate Court in which the action is filed?

(10) Is anyone holding any money for you? If so, name the person, their relationship to you, their

address and the amount of money they are holding.

(11) Do you own any rental properties, by yourself, with someone else or in trust? If the answer is yes:

(a) Is the property residential or commercial?

(b) Please identify the location of the property or properties, include the address and identify your

ownership interest.

(c) Do you derive any income from the property? Do you calculate your net income from the property

on a weekly, monthly or yearly basis?