Field offices in Arkansas, Louisiana, New Mexico, and Oklahoma should continue to
follow all other instructions in SI 00830.400. with the exception of asking for written confirmation of AFDC information provided orally by the AFDC
State agency.
The SS-RVI-310, AFDC Grant Information, is optional and can be used to record oral
information obtained from the AFDC agency.
Current procedures continue to apply in Texas.
AFDC GRANT INFORMATION
Date: __________ SSN: ________________
SSI Recipient: ________________________________________________
Date of SSI Entitlement: ____________________
Approximate Date of Receipt of First SSI Check: _______________
The following information was obtained from:
AFDC Caseworker: ___________________ Phone #: _______________
Agency: ________________ Location: ________________________
The AFDC grant amount for each month the individual is both entitled to SSI and included
in the AFDC grant is:
Mo/Yr
|
Thru
|
Mo/Yr
|
Monthly Grant Amount
|
Grant Amount if SSI Recipient Is Removed
|
______
|
-
|
______
|
__________
|
_____________________
|
______
|
-
|
______
|
__________
|
_____________________
|
______
|
-
|
______
|
__________
|
_____________________
|
______
|
-
|
______
|
__________
|
_____________________
|
______
|
-
|
______
|
__________
|
_____________________
|
Name of Caretaker included in the grant: _______________________
Names of all persons included in the AFDC grant: _______________
The last month the SSI recipient will be included in the AFDC grant is _______________________.
Remarks: _______________________________________________________
________________________________________________________________
________________________________________________________________
Information obtained by: ________________________________
(Name and Position)
SS-RVI-310 (04/94)