CPT Eligibility for Government Benefits

1

What is Your Name?* This field is required.

First Name

Last Name

2

I am a...* This field is required.

Person with a Disability or Injury

Attorney

Settlement Consultant

Friend or Family Member

3

Is anyone in the household receiving Supplemental Security Income?If the individual is receiving ≤ Single = $783,* Married = $1,157* In CA if the individual is receiving ≤: Single = $943.72*, Couple = $1,582.14* Though not typically required, requesting a Benefits Verification Letter from a local Social Security Office or at ssa.gov/myaccount may help if you are unsure.

Yes

No

I'm Not Sure

4

Is anyone in the household receiving Medicaid and any form of income from Social Security (or are they unable to earn gainful employment over $1,260 a month)?Though not typically required, requesting a Benefits Verification Letter from a local Social Security Office or at ssa.gov/myaccount may help if you are unsure.

Yes

No

I'm Not Sure

5

Will anyone in the household apply for “disability income” with The Social Security Administration or medical insurance (Medicaid) post-settlement?“Disability income” = Supplemental Security Income “SSI”, or Social Security Disability Insurance “SSDI”

YESNO

6

Is there a threat of misappropriation?

Yes

No

Unsure

7

What is Your Preferred Contact Method?* This field is required.

Phone

Email

8

What is Your Phone Number?

Area Code

Phone Number

9

What is Your Email Address?

example@example.com