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List your monthly income (Including any income of your spouse or any dependent relative living in the household with you) from: Monthly Income Social Security Benefits $ Supplemental Security Income Payment $ State or Local Welfare Payment. Specify: $ Other benefits, such as Veterans Administration, Civil Service, Unemployment, Black Lung, FECA, Railroad, Private Pension, etc. Specify: $ Earnings (take-home wages and average net earnings from self-employment). Specify: $ Other income, such as dividends, interest, rentals, roomers or boarders, etc. Specify: $ Total Monthly income 4. Do you support, either fully or in part, anyone other than yourself? If "Yes", give the following information about each person you support: Name Yes Address $ No Age Relationship To You (If None, Enter "None") Monthly Payment ëò Ô·-¬ ¬¸» «-«¿´ »¨°»²-»- ±º §±«® ¸±«-»¸±´¼ ±² ¿ ³±²¬¸´§ ¾¿-·Rent or Mortgage, including Property Tax $ Food $ Clothing $ Utilities (electricity, gas, fuel, telephone, water) Other expenses (Such as: Miscellaneous household expenses, medical and dental care (not covered by insurance), automobile expenses or other transportation costs, personal necessities.) $ $ Other Debts Being Paid By Monthly Installments Creditor Monthly Payment Amount Owed $ $ Total Monthly Expenses $ American LegalNet, Inc. www.FormsWorkflow.com 6. Not counting your home, family automobile, or household furnishings, do you or your spouse own any valuable property No Yes or real estate? If "Yes", specify and give current market value. If mortgage, show amount of mortgage. - 7. List below any funds you have (including those of your spouse, if you live with your spouse): a. Cash on hand $ b. Checking account balance $ c. Savings account balance $ d. Current value of any stocks and bonds $ e. Value of other personal property and other funds $ $ TOTAL f. Name of stocks and bonds you have (use separate sheet if space is insufficient). g. Name and address of financial institution (s) PART III - WITHOUT FAULT STATEMENT 8. Explain fully why you thought the incorrect payment was due you and why the overpayment was not your fault: 9. Did you report the change in circumstances which affected your monthly payment? If "Yes", when did you report? (Give date): Yes No There was no change If "No", why didn't you report? American LegalNet, Inc. www.FormsWorkflow.com 10. When were the conditions under which you could receive payments first explained to you? 11. Do you NOW fully understand reporting responsibilities? Yes No If "No", explain: PART IV - REPRESENTATIVE PAYMENT MADE (to be completed ONLY by a representative payee) 12. Give the name and present address of the person for whom you received payment: 13. Were the incorrect payments used for this person? Yes No Explain: PART V 14. Remarks (optional): I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right to payment under the Federal Coal Mine, EEOICPA and FECA Acts commits a crime punishable under Federal and/or State law. I affirm that all information I have given in this document is true. (Date - Month, day, year) (Signature of Overpaid Person or Representative Payee) (Telephone Number) Mailing Address (Number and Street, Apt. No., P.O. Box, Rural Route) City and State ZIP Code County (if any) in which you now live: American LegalNet, Inc. www.FormsWorkflow.com