SI CHI00830.122 (OH) Exhibit II - CDHS/SSA Inter-Agency Referral Form
CCDHS/SSA INTER-AGENCY REFERRAL FORM
SUPPLEMENTAL SECURITY INCOME
IDENTIFYING INFORMATION DATE:
NAME ___________________________ SOC. SEC. NO._________________
LAST FIRST MI
ADDRESS _____________________ CASE NO. ________________________
CITY _______________ ZIP CODE ____ BIRTHDATE ____________________
TELEPHONE NO. ____________ MARITAL STATUS (M) ____(S)_____
SSA
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CCDHS
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Is applicant currently receiving Social security benefits (SSA, SSI)? Yes _____ No _____
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Is applicant currently receiving Welfare benefits?
Yes _____ No _______
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If so, how much per month? _______
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If so, how much per month? _______
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Eligible for SSI?
Yes ____ No ___ Pending ____
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What assistance category? __________
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Date Applied for ______________
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Date Welfare applied for ______
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Advance payment given
Yes __ No __
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Type Welfare applied for ______
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Date given _________________
Amount ________________
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Eligible for Welfare
Yes ___ No ___
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Estimated date of first check _____
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Estimated Date of first check _______
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Amount of assistance approved per month _______________
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Amount of assistance approved per month ________
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Is applicant receiving any other pension Yes ___ No____
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Is applicant receiving any other pension Yes ___ No____
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If so, please indicate source and amount per month. _________
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If so, please indicate source and amount per month. _________
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Reason for Referral ___________
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Reason for Referral ___________
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TO: _______________________
_________________________
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FROM: _____________________
SIGNATURE________________________
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