| PATIENT | INDIVIDUAL ANNUAL INCOME | MARRIED LAST CALENDAR YEAR | LIVED WITH PATIENT | AMOUNT CONTRIBUTED TO SPOUSE | DEPENDENT CHILDREN | INCAPABLE OF SELF-SUPPORT | CONTRIBUTED TO SUPPORT | CHILD HAD INCOME | INCOME AVAILABLE TO YOU | NUMBER OF DEPENDENT CHILDREN | MARRIED THIS YEAR | LIVING WITH PATIENT | RESIDING IN THE COMMUNITY | LEGALLY SEPARATED | CHILD 18-23 IN SCHOOL | AMOUNT CONTRIBUTED TO CHILD | CONTRIBUTED TO SPOUSAL SUPPORT | ANNUAL MEANS TEST |
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