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
 _________________________
 _________________________
 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 : ________________________
_________________________________________________________________
_________________________________________________________________
___AFDC Grant amount minus 1 person _________________
___Grant Termination Date ____________________
___Other________________________________________________________
________________________________________________________________
________________________________________________________________

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500830123CHI
SI CHI00830.123 - (OH) Exhibit III - CCDHS FAX Verification Form - 10/15/2001
Batch run: 01/27/2009
Rev:10/15/2001