Forms Manual

IM-2A Blind Pension Supplement

PURPOSE: To provide, as required by law, a certificate of two householders attesting that the claimant for Blind Pension is of good moral character.

NUMBER OF COPIES AND DISTRIBUTION: File the original behind the application in the Income Maintenance section. It is a permanent part of the case record.


INSTRUCTIONS FOR COMPLETION: Two property owners that live in the same county and who know the claimant complete the form in ink. Complete the IM-2A at each application, reapplication, and any time the worker has reason to question the validity of the claimant’s statement.

CASE NAME: Enter the case name of the claimant.

CASE DCN: Enter the Departmental Client Number (DCN) of the claimant.

DATE: Enter the date the letter is completed.

ADDRESS: Enter the complete address of the claimant.

HOUSEHOLDER’S CERTIFICATE: Enter the name of the county in which claimant resides on the blank on the second line. The Blind Pension Law requires that two disinterested and responsible householders of the same county, who have known the claimant for at least two years, must sign each application. His/her signature will be used as verification of the requirement that the claimant must be “of good moral character”. Ask the claimant to suggest the persons who should sign the certificate. Provide all possible assistance to the claimant in completing the application.

NOTE: If the applicant requests an Application – Eligibility Statement to apply for Blind Pension, always include form IM-2A.