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SOURCE OF INCOME OR SUPPORT AT ADMISSION
TEDS – SUPPLEMENTAL – BUT NOT SOMMS
SOURCE OF INCOME OR SUPPORT SUDS 9
DESCRIPT ION: IDENTIFIES T HE CLIENT 'S PRINCIPAL SOURCE OF FINANCIAL SUPPORT . FOR CHILDREN UNDER 18, T HIS FIELD INDICATES T HE
PARENT 'S PRIMARY SOURCE OF INCOME/ SUPPORT .
VALID ENT RIES: 01 WAGES /S ALARY
02 PUBLIC ASSISTANCE
03 R ETIREMENT/P ENSION
04 DISABILITY
20 OTH ER
21 NO NE
97 UNKNOWN
98 NO T CO LLECTED
UNKNOWN (97) U SE T HIS CODE IF THE ST ATE COLLECT S T HESE DATA, BUT FOR SOME REASON THIS RECORD DOES NOT REFLECT AN
ACCEPT ABLE VALUE.
NO T CO LLECTED (98) U SE T HIS CODE IF THE ST ATE DOES NOT COLLECT THESE DAT A FOR SUBMISSION T O TEDS. NOT COLLECTED IS ALSO
USED WHEN THE ST AT E COLLECT S ONLY A SUBSET OF THE CATEGORIES IN T HE LIST ABOVE.
ST ATES ARE ENCOURAGED T O COLLECT AND REPORT DATA FOR ALL CATEGORIES IN T HE LIST OF VALID ENT RIES SHOWN ABOVE. COLLECT ING
AND REPORTING A SUBSET OF T HE CAT EGORIES IS ALSO ACCEPT ABLE. IF THE ST ATE COLLECT S ONLY A SUBSET OF T HE CATEGORIES, CLIENT S
NOT FITTING T HE COLLECT ED SUBSET MUST BE CODED AS 98 NOT COLLECTED. (FOR EXAMPLE, IF T HE ST ATE COLLECT S ONLY ―PUBLIC
A SSI ST ANCE‖, ALL OT HER CATEGORIES OF SOURCES OF INCOME/SUPPORT MUST BE CODED AS 98).
GPRA
4. Approximately, how much money did YOU receive (pre -tax individual income) in the past 30 days from…
RF DK
a. Wages $ |__|__|__| , |__|__|__| .
b. Public assistance $ |__|__|__| , |__|__|__|
c. Retirement $ |__|__|__| , |__|__|__|
d. Disability $ |__|__|__| , |__|__|__|
e. Non-legal income $ |__|__|__| , |__|__|__|
f. Family and/or friends $ |__|__|__| , |__|__|__|
g. Other (Specify) $ |__|__|__| , |__|__|__|
__________________
The intent is to record the amount of money received by the client in the last 30 days. Do not count money earned by a
spouse or other members of the household, only money earned by the client.
In some instances you may need to ask the client their hourly, daily, weekly, or monthly wage to determine pre-tax
income.
For example, if the client tells you that he/she brings home $100 per week, you will need to ask how much he/she gets
paid per hour and how many hours he/she works per week to arrive at a pre-tax income.
D4a Wages—Money earned through legal full- or part-time employment. Payments made ―under-the-table‖ to avoid
wage garnishments, taxes, etc., if earned legally would be counted here, even if work is performed within a family
business.
D4b Public Assistance—Money received from Temporary Assistance to Needy Families (TANF); welfare; food
stamps; housing vouchers; transportation money; or any other source of social, general or emergency assistance funds.
Additionally, money made from work fair or other programs within which clients work for assistance money should be
recorded here.
D4c Retirement—Money received from 401k plans, Social Security, military retirement, or pensions.
D4d Disability—Money received from Supplemental Security Income, worker’s compensation, or veteran disability
payments.
D4e Non-legal income—Count as non-legal income any money received from illegal activities, such as drug dealing,
stealing, fencing or selling stolen goods, panhandling, illicit gambling, or illegal prostitution. If a client has received
drugs in exchange for illegal activity, do not convert to a dollar amount.
D4f Family and/or Friends—Count allowance and monetary gifts.
D4g Other—Money received legally from any other sources such as trust fund payments, recycling, gambling if
from legal sources (lottery payments, casinos, etc.), alimony, child support, tribal per capita funds, death benefits, stock
options.
Cross-Check Items
Cross-check item D4a with ite m D3. If the client reports either full- or part-time employment in D3, but reports $0 for
wages in D4a, probe to ensure this is correct.
Cross-check item D4b with item D3. If the client reports that he/she is unemployed, looking for work in D3, but
reports $0 for public assistance in D4b, probe to ensure this is correct.
Cross-check item D4c with ite m D3. If the client reports that he/she is unemployed and retired in D3, but reports $0 for
retirement income in D4c, probe to ensure this is correct.
Cross-check item D4d with item D3. If the client reports that he/she is unemployed and disabled in D3, but reports $0
for disability income D4d, probe to ensure this is correct.
South Carolina
Admission and Discharge
Primary Source of Income/Support
Enter the client’s primary source of income/
support. For youth under age 18, indicate
parent’s source of income-support.
01 Wage/Salary
02 Public Assistance
03 Retired/Pension
04 Disability
05 Trust Fund-Inheritance-Allowance
06 Non-Legal Income
20 Other Income or Support
21 No Income or Support
For dependent children under 18, indicate the parents' primary source of income/support.
For non-working adults supported by a spouse, indicate 20, Other Income or Support.
The selection made in this field should have the highest income amount in the Monthly Income field.
Edits will be performed in your software and at DAODAS to verify that this is the case.
Monthly Income
Approximate ly, how much money (or cash
value) did the CLIENT receive (gross individ-
ual income before taxes) in the past 30 days
from:
Wages-Salary 0 0
All Public Assistance
(TANF, Food Stam ps, 0 0
WIC, etc.)
Retirement (Social Secu- 0 0
rity, Pensions)
Disability Payments 0 0
Trust Fund- Inheritance-
Allowance
0 0
Non-Legal Income 0 0
0 0
Enter the client's monthly income for the past 30 days for each of the seven listed income sources.
For clients under 18, enter their parents' income information.
For non-working adults supported by a spouse, indicate income in Other Income or Support.
If the client receives more than $10,000 per month from any one income source, enter 9999.
If no income is received in specific categories, zeros must be entered instead of leaving the categories blank. This
clearly indicates the difference between no income in a category and a category that may have been skipped.
If the client refuses to answer one of the categories enter -001 (negative 1) in the field, if your form/software does not
include a refused checkbox.
Total client income can be stored in a calculated field by summing the income and support values from the component
items.
Verify that answers provided in this block are logical compared to the answers provided in the 30-Day Employment
Status and Primary Source of Income/Support fields.
For example, you would not expect a person with a 30-day employment status of not in labor force-retired to receive
the majority of their income from wages-salary.
Texas
Adult Admission
Primary Source of income or support for family during the 12 months pri or to admission
None Disability Other
Wages/Salary Unemployment TANF/Welfare to
compensation work
Public Assistance Family/friend support Unknown
Retirement Illegal gain
pension
Secondary Source of income or support for family during the 12 months prior to admission
None Disability Other
Wages/Salary Unemployment TANF/Welfare to
compensation work
Public Assistance Family/friend support Unknown
Retirement Illegal gain
pension
Youth Admission
Primary Source of income or support for family during the 12 months prior to admission
None Disability Other
Wages/Salary Unemployment TANF/Welfare to
compensation work
Public Assistance Family/friend support Unknown
Retirement Illegal gain
pension
Secondary Source of income or support for family during the 12 months prior to admission
None Disability Other
Wages/Salary Unemployment TANF/Welfare to
compensation work
Public Assistance Family/friend support Unknown
Retirement Illegal gain
pension
Florida
Primary Income Source
This item indicates the client’s primary source of income at the time of this performanc e evaluation. This should only
reflect the income generated by the client. Client income does not include that of a spouse, a parent, etc.
Adolescents with a source of income should be coded appropriately.
If several sources of inc ome are known, i.e., more than one code applies, use the highest dollar figure source to
determine which is primary.
Enter the code from the list below that matches the client’s primary source of income.
[1] = Salary – Compensation for services, paid to the client on a regular basis. .
[2] = TANF – Income received by the client thro ugh the Temporary Assistance to Needy Families
Program
[3] = Retirement/Pension/SSI – Income received by the client for fulfilling certain conditions of
prior employment.
[4] = Disability – Income received by the client, usually from government or insurance sources, for
prior handicapping conditions. This includes SSDI.
[5] = Other – Non-specified income including “illegal” income.
[6] = None – Client has no source of income. Do not use this for unknown income sources.
[7] = Unknown – Use this code if you can’t determine the source of the client’s income.
Receives Psychiatric Disability Income?
This item indicates if the client is receiving dis ability income for a psychiatric condition, e.g., SSI, SSDI, Veterans.
Use code 0 if the client receives this income for only a non-psychiatric condition.
Enter the code from the list below that matches the correct ans wer, either “No” or “Yes”:
[0] = No, the client doe s not receive this type of income.
[1] = Ye s, the client doe s rec eive this type of income.
Florida
09 Monthly Income from Paid Employment
This item is a maximum 4-digit number indicating the total MONTHLY income earned by the client from paid
employment in the last 30 days. If the client actually has no income, enter 0 (zero).
Valid values are 0 through 9999. If you know the amount, enter a value from 0 through 9998. If the amount is greater
than 9998, use 9998. If the amount is unknown, use 9999.
For a person who started the episode of care as a child and turns 18 during the episode of care,
this field is not required. If the agency elects to switch the target population to an adult, do the
following: discharge the person prior to their 18 th birthday and readmit the person after their 18 th
birthday. Then enter the appropriate amount of paid income.
10 Monthly Income from Government Sources
This item is a maximum 4-digit number indicating the total MONTHLY income received by the client from government
subsidies in the last 30 days. If the client actually has no income, enter 0 (zero).
Examples of subsidy include Social Security retirement, Supplemental Security Income (SS I), Optional State
Supplement ation (OSS), Social Security Disability Inc ome (SS DI), and public assistance.
Valid values are 0 through 9999. If you know the amount, enter a value from 0 through 9998. If the amount is greater
than 9998, use 9998. If the amount is unknown, use 9999.
For a person who started the episode of care as a child and turns 18 during the episode of care,
this field is not required. If the agency elects to switch the target population to an adult, do the
following: discharge the person prior to their 18 th birthday and readmit the person after their 18th
birthday. Then enter the appropriate amount of government income.
11 Monthly Income from Other Sources
This item is a maximum 4-digit number indicating the total MONTHLY income received by the client from sources
other than paid employment or government subsidies in the last 30 days.
Examples of other income include subsidies or allowances given to the client by family members or other relatives,
illegal income, lottery winnings, inheritances, etc.
Valid values are 0 through 9999. If you know the amount, enter a value from 0 through 9998. If the amount is greater
than 9998, use 9998. If the amount is unknown, use 9999.
For a person who started the episode of care as a child and turns 18 during the episode of care,
this field is not required. If the agency elects to switch the target population to an adult, do the
following: discharge the person prior to their 18 th birthday and readmit the person after their 18 th
birthday. Then enter the appropriate amount of other income.
Maine
21. PRIMARY SOURCE OF HOUSEHOLD INCOME/SUPPORT
(LAST 30 DAYS)
Enter the code for the primary source of household income/support in the last 30 days.
00 - None 07 - Disability, Other
01 - Wages/Salary 08 - Town Welfare
(Includes commissions 09 - Child Support
and self employment) 10 - Unemployment Benefits
02 - Retirement 11 - Social Security
03 - Alimony 12 - Dealing Drugs
04 - Food Stamps 13 - Worke r's Compensation
05 - TANF(formerly AFDC) 99 - Other (i.e. investments)
06 - SSI
NOTE: If you said income 0000 for # 20, then source should be 00. If you entered other than 0000 for # 20, then
source should not be 00.
22. SECONDARY SOURCE OF HOUSEHOLD INCOME/SUPPORT (LAST 30 DAYS) IF DIFFERENT
FROM PRIMARY
Enter the code for the secondary source of household income/support in the last 30 days. If different from the
Primary. DO NOT enter the same code twice (unless 00)
00 - None 07 - Disability, Other
01 - Wages/Salary 08 - Town Welfare
(Includes commissions 09 - Child Support
and self employment) 10 - Unemployment Benefits
02 - Retirement 11 - Social Security
03 - Alimony 12 - Dealing Drugs
04 - Food Stamps 13 - Worke r's Compensation
05 - TANF(formerly AFDC) 99 - Other (i.e. investments)
06 - SSI
Maryland
Primary Source of Income/Support
Select one of the following categories. If more than one category applies, enter the source that provides the greatest part
of the patient's income/support.
1 Wages/Salary
This category indicates taxable payments of moneys received for labor of services rendered.
2 Public Assistance/TCA
These are patients identified and referred by DSS under the Maryland Welfare Innovation Act of 1997 (Department of
Social Services) to receive substance abuse treatment as a condition of the receipt of benefits.
3 Self- Employment
This category includes patients who work for themselves or have their own businesses.
4 Retirement/Pension
This category includes patients who received a fixed sum of money following the conclusion of their careers.
5 Unemployment Compensation
This category includes patients who receive compensation paid at regular intervals (by a government agency) due to a
layoff.
6 Disability
This category includes patients who have a physical, sensory or mental impairment which seriously affects their day-to-
day activities on a long-term basis.
7 Other
This is any other source of income/support that is not mentioned above, e.g., alimony, child-support.
8 Unknown
Minnesota
Primary Source of Income:
(01) Disability benefits
(02) Job
(03) Retirement/pension
(04) Spouse/parents
(05) Relatives/friends
(06) Savings or investments
(07) Public assistance
(08) Other
(09) None
(99) Unknown
New Jersey
Does anyone contribute to the MAJORITY of your support in any way?
(Like giving you money, food, housing)
1. No
2. Yes
During the past 6 months, did you receive any of the following public assistance?
1. Temporary Aid to Needy Families – TANF (welfare assistance for people with children)
2. General Assistance – GA (welfare assistance for people without children)
3. SSI or Disability Insurance (Social Security Disability)
4. Food Stamps or WIC
5. Did not receive any Public Assistance
In the past 6 months, how many months have you received any public assistance? _____ months
New York
CLIENT’S PRIM ARY S OURCE OF INC OM E
Enter the category which corresponds to the primary or major source of income for the client, either currently or in
the 30 day period prior to a dmission. If the client ’s Em ployment Status is “Not in Labor Force,” the primary source of
income cannot be “ Wages/Salary.”
None
Wages/Salary This category should be used only if it relates to the client ’s wages/salary. Wages/Salary of the
client’s spouse/family should be indicated by Family and/or S pouse Contribution.
Alimony/Child Support
Department of Veterans Affairs
Family and/or Spouse Contribution
SSI/SSDI or SSA
Safety Net Assistance
Temporary Assistance For Needy Families TANF provides cash assistance to eligible needy familie s that include
a minor child living with a parent (including families where both parents are in the household), or a caretaker
relative.
Other
Washington
SOURCE OF INCOME
Field Description Indicates the client's current primary source of income.
Disability Compensation
Family/Friend (most youth fall here)
None
Other
Public Assistance
Retirement Pension
Supplemental Security Income (SSI)
Unemployment Compensation
Wages/Salary
Ohio
19. INCOME SOURCE: (Positions 103-105)
This field denotes client's income/source. *Primary denotes the client's major source of income (not household
income sources). If the client has only one source of income or no income, only position ―1‖ is to be
completed. If the client has two sources of income, only complete ―1‖ and ―2‖. If the client has three sources of
income, complete positions 1, 2 and 3. If the client has more than three sources of income, this item represents
the highest three sources.
A. Wages/Salary Income: refers to payment received for work done by the client. This work can be part-
time, full-time or sheltered employment.
B. Family or Relative: refers to income provided to the client by the family or a relative. *NOTE: Any
wages the child earns are considered income. A homemaker supported by a spouse should be reported as
having no income.
C. Alimony: refers to income received from alimony payments.
D. Child Support: refers to income received from child support payments.
E. Savings or Investments: refers to income derived from savings accounts earned on investments or
generated by the sale or surrender of investment options.
F. Disability Insurance/Worker's Compensation: refers to income received from private disability
insurance or Worker's Compensation for a permanent or temporary disability.
G. Une mployme nt Compensation: refers to income received from the State or Federal government for loss
of employment.
H. Retirement Pension: refers to income from a public or private retirement program, not social security
retirement.
I. Social Security Retire ment: refers to income from social security retirement.
J. General Relief/Welfare: refers to a need-based program of financial assistance for people ineligible for
federal programs. The program is administered by county Ohio Department of Human Services offices.
K. Aid for Dependent Childre n (ADC or AFDC): refers to a program administered by county Ohio
Department of Human Services offices designed to meet the financial needs of children and their care-
takers. *NOTE: ADC is considered the child's income if Human Services has taken custody of the child
and the ADC funds are issued in the child's name.
L. Suppleme ntal Security Income (SSI): refers to a federal need-based program providing monthly paym
ents to aged, blind and disabled persons. *NOTE: Social Security checks (SSI or SSDI) issued in the child's
name should be considered the child's income.
M. Social Security Disability Insurance (SSDI): refers to a federal program providing cash benefits to
disabled workers and their dependents. SSDI is sometimes referred to as Title II. *NOTE: Social Security
checks (SSI or SSDI) issued in the child's name should be considered the child's income.
N. Other: refers to other income sources that can be identified but are not mentioned on this record.
P. None: refers to a client with no income.
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