SI CHI00830.121 (OH) Exhibit I - Sample Letter For Notifying AFDC

 FO Address
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
___________________ ________ _______________
 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

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SI CHI00830.121 - (OH) Exhibit I - Sample Letter For Notifying AFDC - 10/15/2001
Batch run: 04/29/2015