SI CHI00830.117 (MN) Exhibit I - Sample Letter for Notifying AFDC

 FO Address

 Date:

Department of Health and Social Services Address

To Whom It May Concern:

We have been informed that ______________(NAME) ______________ ______________________ (ADDRESS) ____________________________ has been receiving AFDC payments. This individual has filed for Supplemental Security Income (SSI) payments and is eligible for payment. Our records show the following information.

Social Security Number __________ Date of Entitlement __________ 

AFDC Claim Number _________ Estimated Date of First Check _______

Type of Benefit: Aged _____ Blind _____ Disabled _____ 

The SSI payment will be adjusted to take into account the AFDC payment being made. Please verify the amount of the family's AFDC payment including  (NAME)  and the amount the AFDC payment would have been if  (NAME)  had not been included in the grant.

Please notify us of the termination date of the AFDC payment so we can adjust the SSI payment. We need this information monthly for the entire period requested (from the SSI date of entitlement through the AFDC termination date). Be sure to provide the grant amounts for any months the AFDC payment changed. Please complete the information below and return this form in the envelope provided. If you have any questions, please contact

___________________ ________ _______________

NAME (SSA EMPLOYEE) TITLE TELEPHONE NUMBER

 Sincerely,

 District Manager

Claimant's Name ________________________________________________

Date the AFDC grant will no longer include (claimant): ________

 Total Cash Grant Amount             Total Grant Amount

Month(s)    Including Claimant(s)      Without Claimant(s)

______________________ ____________ ______________ _______

Name(AFDC Worker) Title Phone Number Agency Name Date