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
CCDHS
Is applicant currently receiving Social security benefits (SSA, SSI)? Yes _____ No _____
Is applicant currently receiving Welfare benefits?
Yes _____ No _______
If so, how much per month? _______
If so, how much per month? _______
Eligible for SSI? 
Yes ____ No ___ Pending ____
What assistance category? __________
Date Applied for ______________
Date Welfare applied for ______
Advance payment given 
Yes __ No __
Type Welfare applied for ______
Date given _________________
Amount ________________
Eligible for Welfare 
Yes ___ No ___
Estimated date of first check _____
Estimated Date of first check _______
Amount of assistance approved per month _______________
Amount of assistance approved per month ________
Is applicant receiving any other pension Yes ___ No____
Is applicant receiving any other pension Yes ___ No____
If so, please indicate source and amount per month. _________
If so, please indicate source and amount per month. _________
Reason for Referral ___________
Reason for Referral ___________
TO: _______________________
_________________________
FROM: _____________________
SIGNATURE________________________

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500830122CHI
SI CHI00830.122 - (OH) Exhibit II - CDHS/SSA Inter-Agency Referral Form - 10/15/2001
Batch run: 01/27/2009
Rev:10/15/2001