| SVGN4001 |
| No | Yes | |
| SVGN4002 |
| Household Gross Income Test (en) |
| No | Yes | |
| SVGN4003 |
| Household Net Income Test (en) |
| No | Yes | |
| SVGN4004 |
| No | Yes | |
| SVGN4005 |
| Household Members Eligibility Summary (en) |
| No | Yes | |
| SVGN4006 |
| Gross Countable Income (en) |
| No | Yes | |
| SVGN4007 |
| Net Countable Income (en) |
| No | Yes | |
| SVGN4008 |
| Resource Test for Household (en) |
| No | Yes | |
| SVGN4009 |
| Household Member Resource Totals (en) |
| No | Yes | |
| SVGN4010 |
| Household Members Resource Summary (en) |
| No | Yes | |
| SVGN4011 |
| No | Yes | |
| SVGN4012 |
| No | Yes | |
| SVGN4013 |
| Uncountable Resources (en) |
| No | Yes | |
| SVGN4015 |
| Household Non Financial Eligibility Summary (en) |
| No | Yes | |
| SVGN4016 |
| Participant Non Financial Eligibility Summary (en) |
| No | Yes | |
| SVGN4017 |
| No | Yes | |
| SVGN4018 |
| No | Yes | |
| SVGN4019 |
| Household Sanctioned (en) |
| No | Yes | |
| SVGN4020 |
| Household Eligibility Determination (en) |
| No | Yes | |
| SVGN4021 |
| No | Yes | |
| SVGN4022 |
| Household Member Income Totals (en) |
| No | Yes | |
| SVGN4023 |
| No | Yes | |
| SVGN4024 |
| No | Yes | |
| SVGN4025 |
| Household Member Sanctioned (en) |
| No | Yes | |
| SVGN4026 |
| Eligibility Determination (en) |
| No | Yes | |
| SVGN4027 |
| No | Yes | |
| SVGN4028 |
| Institutionalized Individual Non Financial Details (en) |
| No | Yes | |
| SVGN4029 |
| LTC Gross Income Test (en) |
| No | Yes | |
| SVGN4030 |
| Post Eligibility Income Test (en) |
| No | Yes | |
| SVGN4031 |
| Blind/Disabled Child (en) |
| No | Yes | |
| SVGN4032 |
| Single Institutionalized Individual (en) |
| No | Yes | |
| SVGN4033 |
| Married Couple Both Institutionalized (en) |
| No | Yes | |
| SVGN4034 |
| Married Institutionalized Individual with Community Spouse (en) |
| No | Yes | |
| SVGN4035 |
| No | Yes | |
| SVGN4036 |
| LTC Facility SpendDown (en) |
| No | Yes | |
| SVGN4037 |
| No | Yes | |
| SVGN4038 |
| Non Countable Resources (en) |
| No | Yes | |
