SI CHI00830.123 (OH) Exhibit III - CCDHS FAX Verification Form

 FAX TRANSMITTAL SHEET

 DEPARTMENT OF HUMAN SERVICES

 ATTN: ROSEMARY WELCH

 FAX NUMBER - 987-6617

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 FROM SOCIAL SECURITY ADMINISTRATION

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 FAX NUMBER_______________________ 

 ANY QUESTIONS CALL _________________

 REQUEST DATE: ___________________

WE NEED TO HAVE THE FOLLOWING INFORMATION REGARDING:

Name _______________________________ SSN ____________________

Case Number _______________________ Program _________________

Case Name _____________________________

Award/Grant Amt ______________________ Starting Date ___________

Award/Grant Amt ______________________ Starting Date ___________

Food Stamp Amt _______________________ Starting Date ___________

(Please check additional items needed)

____Persons covered in the AFDC grant : ________________________

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___AFDC Grant amount minus 1 person _________________

___Grant Termination Date ____________________

___Other________________________________________________________

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