SI BOS02003.001 Connecticut Interim Assistance Reimbursement Agreement

See SI 02003.000ff

A. Introduction

On December 16, 1974 the Connecticut Department of Social Services (DSS) entered into an Interim Assistance Reimbursement (IAR) Agreement with the Social Security Administration (SSA). This agreement was updated and renewed on May 7, 2001 and modified on November 28, 2001. The IAR Agreement covers both initial and posteligibility situations.

B. Policy

1. Initial and Posteligibility Periods Covered

The IAR Agreement with the Connecticut Department of Social Services provides for reimbursement to DSS for General Assistance provided to the SSI recipient for initial claims and posteligibility situations. For initial claims the reimbursement covers the General Assistance paid for the interim period while the SSI application is pending. For posteligibility situations the reimbursement covers the General Assistance paid by DSS to an individual for the interim period while his/her SSI benefits are suspended or terminated if the individual is subsequently found to be eligible for SSI during those months. The interim period is described in SI 02003.001.

2. Protective filing

The IAR authorization serves as a protective filing for an initial SSI claim. The date that DSS receives a signed IAR authorization establishes a 60-day protective filing period for SSI eligibility. If an individual does not file an SSI application within the 60-day protective filing period, the IAR authorization does not serve as protective filing for SSI purposes.

3. Life of the Authorization

For initial SSI claims the IAR authorization is binding on the State of Connecticut and an individual for one calendar year beginning with the date SSA receives a signed authorization. If the State of Connecticut does not notify SSA within thirty (30) calendar days of the date that the individual signed the authorization, the authorization is no longer binding. In such a situation, SSA will release a retroactive SSI payment to the individual and the State of Connecticut will be responsible for pursuing recovery of IAR from the individual without assistance from SSA. If an individual applies for SSI within the one calendar year period covered by the IAR authorization or has already applied for SSI before SSA received an authorization, the period for the life of the authorization will be extended beyond the one year period, until such time as:

  • SSA releases the retroactive payment; or

  • SSA makes a final determination (including a determination on appeal) and no timely request for review is filed; or

  • The State and the individual agree to terminate the authorization.

For initial posteligibility cases, the IAR authorization is binding for one calendar year beginning with the date SSA receives a signed authorization. If the State does not notify SSA within thirty (30) calendar days of the date that the individual signed the authorization, the authorization is no longer binding. In such a situation, SSA will release the retroactive SSI payment to the individual and the State of Connecticut will be responsible for pursuing recovery of IAR from the individual without assistance from SSA. If a timely request for administrative or judicial review is filed the IAR authorization remains in effect until such time as:

  • SSA makes the first posteligibility payment of retroactive SSI benefits following the suspension or termination of the individual's benefits; or

  • SSA makes a final determination on the issue and no timely request for appeal is filed; or

  • The State of Connecticut and the individual agree to terminate the authorization.

The Connecticut Department of Social Services must obtain another initial claim or posteligibility authorization if the authorization is no longer in effect and the State wants to be reimbursed for General Assistance payments made.

C. Process

Connecticut DSS uses one multipurpose IAR authorization form (W-650ALT / W- 650ALTS Spanish Version), covering either initial payment or posteligibility payment (Exhibits 1 and 2) for all municipalities but the City of Norwich. Representatives from the City of Norwich use a similar multipurpose IAR authorization form, (W-650/ W-650S Spanish Version) (Exhibits 3 and 4). On each IAR authorization either the Initial Payment Only block or the Initial Posteligibility Payment Only block must be checked. The same authorization form cannot be used for both an initial claim and posteligibility situation. Each time an individual files for SSI or his/her benefits are suspended or terminated another initial claim or posteligibility authorization is required.

D. Procedure

When an IAR authorization is received, input the Grant Reimbursement (GR) code for the Connecticut Department of Social Services to the SSR.

    GR Code DSS: 07010

Mail manually prepared SSA-L8125s and SSA-L8125-F6s to:

Department of Social Services
ATTN: Accounts Receivable
55 Farmington Avenue
Hartford, CT 06105

FAX: 860-424-4962

E. Exhibits

The following exhibits consist of examples of the Connecticut Department of Social Services Interim Assistance Reimbursement Authorization and copies of the apportionment notices sent by the State of Connecticut.

1. Exhibit 1 – Connecticut Department Of Social Services Reimbursement Authorization (State Form W-650ALT)

W-650ALT STATE OF CONNECTICUT

(Rev. 4/01) DEPARTMENT OF SOCIAL SERVICES

AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE TO THE STATE OF CONNECTICUT

A. INITIAL PAYMENT OR INITIAL POSTELIGIBILITY PAYMENT

Applicant's Name ______________________ AU No. ______________

Address ______________________________ Client ID No. __________

City/Town_____________________________ Social Security No. ______________

The term State means the Connecticut Department of Social Services

What am I authorizing the State to do by signing this authorization if I checked the block called Initial Payment Only?

[] Initial Payment Only

If I am found eligible to receive Supplemental Security Income (SSI) benefits, I understand that I am authorizing the Commissioner of the Social Security Administration (SSA) to send to the State:

  • My first retroactive payment of SSI benefits, or

  • An amount equal to the amount of reimbursable General Assistance the State gave to me, if law restricts the manner in which my SSI money can be released to me.

What am I authorizing the State to do by signing this authorization if I checked the block called Initial Posteligibility Payment Only?

[] Initial Posteligibility Payment Only

If I am found eligible to receive SSI benefits, I understand that I am authorizing the Commissioner of SSA to send to the State:

  • My first retroactive posteligibility payment of Supplemental Security Income (SSI) benefits, or

  • An amount equal to the amount of reimbursable General Assistance the State gave to me when law restricts the manner in which my SSI money can be released to me.

How will the State be paid for the reimbursable General Assistance it gave to me if I checked the block called Initial Payment Only?

If I am found eligible to receive SSI money, SSA will send my first retroactive SSI payment to the State or an amount equal to the amount of reimbursable General Assistance the State gave to me when law restricts the manner in which my SSI money can be released to me. The State may:

  • Deduct from my first retroactive SSI payment the sum of all reimbursable State General Assistance benefits made to, or on behalf of, me by the State in situations when law does not restrict the manner in which my SSI money can be released to me, or

    • THIS INFORMATION IS AVAILABLE IN ALTERNATE FORMATS. PHONE (800) 842-1508 OR TDD/TTY (800) 842-4524.

  • Have SSA send it an amount equal to the amount of reimbursable General Assistance the State gave to me when law restricts the manner in which my SSI money can be released to me, for months beginning with:

    • The first month for which I am eligible to receive an SSI payment and ending with the month my SSI payment begins, or

    • The following month if the State cannot promptly stop making its last General Assistance payment to me.

The State cannot be reimbursed for assistance it gave to me if that assistance was financed wholly or partly from Federal dollars.

How will the State be paid for the reimbursable General Assistance it gave to me if I checked the block called Initial Posteligibility Payment Only?

If I am found eligible to receive SSI money, SSA will send my first retroactive posteligibility SSI payment to the State or an amount equal to the amount of reimbursable General Assistance the State gave to me when law restricts the manner in which my SSI money can be released to me. The State may:

  • Deduct from my first retroactive posteligibility SSI payment the sum of all reimbursable State General Assistance benefits made to, or on behalf of, me by the State in situations when law does not restrict the manner in which my SSI money can be released to me, or

  • Have SSA send it an amount equal to the amount of reimbursable General Assistance the State gave to me when law restricts the manner in which my SSI money can be released to me, for months beginning with:

    • The first day of the month in which my SSI payments resume following a period of suspension or termination and ending with, and including the month my SSI payments resume, or

    • The following month if the State cannot promptly stop making its last General Assistance payment to me.

The State cannot be reimbursed for assistance it gave to me if that assistance was financed wholly or partly from Federal dollars.

Can the State use this authorization for an Initial Payment of SSI benefits and an Initial Posteligibility Payment of SSI benefits?

No, I am authorizing the State to use this form for only one payment event. If both payment blocks are checked, this form is not binding on the State or me. If both blocks are checked, the State and I must sign a new form with only one of the payment blocks checked.

Does this authorization serve as a protective filing for SSI benefits?

Yes, if I checked the Initial Payment Block, signing this form serves as a signed statement of my intention to claim SSI benefits if I have not filed an SSI application as of the date this authorization is received by the State. My eligibility for SSI benefits may begin as early as the date I sign this form if I file an application at a Social Security office for SSI benefits within 60 days after that date. This form also serves as a notice from SSA that I have sixty days from the date the State receives this form to file for SSI benefits. However, If I do not file an application for SSI benefits at a Social Security office within 60 days after that date, then I understand that I cancel my intention to claim SSI benefits and this authorization no longer protects my filing date for SSI.

How long is this authorization binding on the State and me if I checked the Initial Payment Block?

If I checked the Initial Payment Block, this authorization is binding on the State and me for one calendar year beginning with the date the State received it. If the State does not notify SSA within thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the State or me. Also, this form must be signed and dated by both a State representative and me to be a valid agreement that authorizes the State to receive interim assistance reimbursement from my SSI payments. However, if I have already applied for SSI before the State received this authorization, or I apply for SSI within one calendar year of the date described above, or I file a timely request for an administrative or judicial review within the time permitted under SSA's regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:

  • SSA makes the initial SSI payment on my initial claim; or

  • SSA makes a final determination on my claim; or

  • The State and I both agree to terminate this authorization.

How long is this authorization binding on the State and me if I checked the Initial Posteligibility Payment Block?

If I checked the Initial Posteligibility Payment Block, this authorization is binding on me and the State for one calendar year beginning with the date the State received it. If the State does not notify SSA within thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the State or me. Also, this form must be signed and dated by both a State representative and me to be a valid Agreement that authorizes the State to receive interim assistance reimbursement from my SSI payments.

However, if I file a timely request for an administrative or judicial review within the time permitted under SSA"s regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:

  • SSA makes the initial SSI posteligibility payment following a suspension or termination of my SSI benefits; or

  • SSA makes a final determination on my appeal; or

  • The State and I both agree to terminate this authorization.

What rights and appeals are available to me under this authorization?

The State is required to:

  1. Pay to me any balance due from the retroactive SSI payment within 10 working days of the receipt of my SSI payment.

  2. Give me written notice explaining:

    • How much SSA repaid the State for interim assistance it gave to me;

    • The balance, if any, due me unless the Social Security Act requires SSA to pay me such balance. (In such an event, SSA will notify me of the manner in which the balance will be paid to me.); and

    • That I will have an opportunity for a hearing with the State if I disagree with it's actions regarding repayment of interim assistance or any action it took regarding this authorization.

______________________                                   _________________     

Signature of Recipient                                                 Date

_______________________________                   _________________

Signature of State Representative                                 Date

________________________________

Printed Name of State Representative

________________________

Phone # Regional Office

2. Exhibit 2 – Connecticut Department Of Social Services Reimbursement Authorization (W-650ALTS Spanish Version, State)

W-650ALTS ESTADO DE CONNECTICUT

(New 4/01) DEPARTAMENTO DE SERVICIOS SOCIALES

AUTORIZACION DE REEMBOLSO DE ASISTENCIA INTERINA AL ESTADO DE CONNECTICUT

A. PAGO INICIAL O PAGO INICIAL POST-ELEGIBILIDAD

Nombre del Solicitante _______________________     No. AU _____________________

Dirección ______________________                         No. ID del Cliente _____________

Ciudad/Pueblo __________________                          No. Seguro Social _____________

El término “Estado” significa el Departamento de Servicios Sociales de Connecticut..

¿Qué yo estoy autorizando al Estado a hacer si firmo esta autorización si yo marco el bloque llamado Pago Inicial solamente?

[] Pago Inicial Solamente

Si yo soy encontrado elegible a recibir beneficios de Ingreso de Seguridad Suplementario (SSI), Yo entiendo que yo autorizo al Comisionado de la Administración del Seguro Social (SSA) a enviar al Estado:

  • MI primer pago retroactivo de beneficios del SSI, o

  • Una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió, si la ley restringe la manera en la cual mi dinero del SSI puede ser relevado a mi.

¿Qué yo estoy autorizando al Estado a hacer si firmo esta autorización si yo marco el bloque llamado Pago Inicial Post-elegibilidad Solamente?

[] Pago Inicial Post-elegibilidad Solamente

Si yo soy encontrado elegible a recibir beneficios de SSI, Yo entiendo que yo autorizo al Comisionado de SSA a enviar al Estado:

  • Mi primer pago retroactivo de post-elegibilidad de beneficios de Ingreso de Seguridad Suplementario (SSI), o

  • Una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió, si la ley restringe la manera en la cual mi dinero del SSI puede ser relevado a mi.

¿Cómo será pagado el Estado por la Asistencia General reembolsable dado a mí si yo marco el bloque llamado Pago Inicial solamente?

Si yo soy encontrado elegible a recibir dinero de SSI, el SSA enviará mi primer retroactivo de pago de SSI al Estado o una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mi. El Estado puede:

  • Deducir de mi primer pago retroactivo de SSI la suma de todos los beneficios de Asistencia General del Estado reembolsables hechos a, o a favor de mí por el Estado en situaciones donde la ley no restringe la manera en la cual mi dinero de SSI puede ser relevado a mi; o

    ESTA INFORMACION ESTA DISPONIBLE EN FORMATOS ALTERNOS. TELEFONO (800) 842-1508 O TDD/TTY (800) 842-4524.

  • Hacer SSA enviar una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí, por meses comenzando con:

    • El primer mes por el cual yo soy elegible a recibir un pago de SSI y terminando con el mes que mi pago de SSI comienza, o

    • El mes siguiente si el Estado no puede prontamente parar de hacer el último pago de Asistencia General a mi.

El Estado no puede ser reembolsado por asistencia dada a mí si esa asistencia fue financiada totalmente o parcialmente de dólares federales.

¿Cómo será pagado el Estado por la Asistencia General reembolsable dado a mí si yo marco el bloque llamado Pago Inicial Post-eligibilidad Solamente?

Si yo soy encontrado elegible a recibir dinero de SSI, el SSA enviará mi primer retroactivo de pago post-eligibilidad de SSI al Estado o una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí. El Estado puede:

  • Deducir de mi primer pago post-eligibilidad retroactivo de SSI la suma de todos los beneficios de Asistencia General del Estado reembolsables hechos a, o a favor de mí por el Estado en situaciones donde la ley no restringe la manera en la cual mi dinero de SSI puede ser relevado a mi; o

  • Hacer SSA enviar una cantidad igual a la cantidad de Asistencia General reembolsable que el Estado me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí, por meses comenzando con:

    • El primer día del mes en el cual mis pagos de SSI se reanudan siguiendo un periodo de suspensión o terminación y terminando con, e incluyendo el mes que mis pagos de SSI se reanudan, o

    • El mes siguiente si el Estado no puede prontamente parar de hacer el último pago de Asistencia General a mí.

El Estado no puede ser reembolsado por asistencia dada a mí si esa asistencia fue financiada totalmente o parcialmente de dólares federales.

¿Puede el Estado usar esta autorización para un Pago Inicial de beneficios de SSI y un Pago Inicial Post –Eligibilidad de beneficios de SSI?

No. Yo estoy autorizando al Estado a usar esta forma para solamente un pago. Si ambos bloques de pago son marcados esta forma no es ligado en el Estado o en mí. Si ambos bloques son marcados, el Estado y yo debemos firmar una nueva forma con solamente uno de los bloques de pago marcado.

¿Sirve esta autorización como una llenada protectiva para beneficios de SSI?

Si, si yo he marcado el Bloque de Pago Inicial, firmando esta forma sirve como una declaración firmada de mi intención a reclamar beneficios de SSI si yo no he llenado una aplicación de SSI para la fecha que esta autorización es recibida por el Estado. Mi elegibilidad para beneficios de SSI puede comenzar tan pronto como la fecha cuando yo firmo esta forma si yo lleno una aplicación en la oficina de Seguro Social para beneficios de SSI dentro de 60 días después de esa fecha. Esta forma también sirve como un aviso de SSA que yo tengo sesenta días de la fecha que el Estado recibió esta forma para llenar por beneficios de SSI. Sin embargo, si yo no lleno una aplicación para beneficios de SSI en la oficina del Seguro Social dentro de 60 días antes de esta fecha, entonces yo entiendo que yo cancelo mi intención a reclamar beneficios de SSI y esta autorización no protege más mi fecha de llenar para SSI.

¿Por cuánto es esta autorización ligada en el Estado y conmigo si yo marco el Bloque de Pago Inicial?

Si yo he marcado el Bloque de Pago Inicial, esta autorización es ligada con el Estado y conmigo por un año comenzando con la fecha que es recibido en el Estado. Si el Estado no notifica al SSA dentro de (30) días calendarios de la fecha que yo firmo esta autorización, la autorización no está ligada con el Estado o conmigo. También, esta forma debe ser firmada y fechada por ambos un representativo del Estado y yo para ser un acuerdo válido que autoriza al Estado a recibir reembolso de asistencia interina de un representativo del Estado y yo para ser un acuerdo válido que autoriza al Estado a recibir reembolso de asistencia interina de mis pagos del SSI. Sin embargo, si yo ya he aplicado para SSI antes de que el Estado recibió esta autorización, o yo aplico por SSI dentro de un año calendario de la fecha descrita arriba, o yo lleno una petición a tiempo para una revisión administrativa o judicial dentro del tiempo permitido bajo las regulaciones de SSA, esta autorización se mantendrá en efecto, aun sí después de un periodo de un año calendario, hasta tal tiempo como:

  • SSA hace el pago inicial de SSI en mi reclamación inicial; o

  • SSA hace una determinación final en mi reclamación; o

  • El Estado y yo ambos estamos de acuerdo a terminar esta autorización.

¿Por cuánto es esta autorización ligada en el Estado y conmigo si yo marco el Bloque de Pago Inicial Post-elegibilidad?

Si yo he marcado el Bloque de Pago Inicial Post-elegibilidad, esta autorización es ligada con el Estado y conmigo por un año calendario comenzando con la fecha que es recibido en el Estado. Si el Estado no notifica al SSA dentro de (30) días calendarios de la fecha que yo firmo esta autorización, la autorización no está ligada con el Estado o conmigo. También, esta forma debe ser firmada y fechada por ambos un representativo del Estado y yo para ser un acuerdo válido que autoriza al Estado a recibir reembolso de asistencia interina de mis pagos del SSI.

Sin embargo, si yo lleno una petición a tiempo para una revisión administrativa o judicial dentro del tiempo permitido bajo las regulaciones de SSA, esta autorización se mantendrá en efecto, aun sí después de un periodo de un año calendario, hasta tal tiempo como:

  • SSA hace el pago inicial post-elegibilidad de SSI siguiendo una suspensión o terminación de mis beneficios de SSI; o

  • SSA hace una determinación final en mi apelación; o

  • El Estado y yo ambos estamos de acuerdo a terminar esta autorización.

¿Qué derechos y apelaciones están disponibles para mi bajo esta autorización?

El Estado es requerido a:

  1. Pagarme cualquier balance debido a retroactivo de Pago de SSI dentro de 10 días laborables del recibo de mi pago de SSI.

  2. Darme un aviso por escrito explicando:

    • Cuánto SSA re-pagó al Estado por asistencia interina dada a mi;

    • El balance, si hay, debido a mi a menos que el Decreto del Seguro Social requiera que SSA me pague tal balance. (En tal evento, SSA me notificará la manera en la cual el balance será pagado a mi.); y

    • Que yo tendré una oportunidad para una audiencia con el Estado si yo no estoy de acuerdo con estas acciones relacionadas a re-pagó de asistencia interina o cualquier acción que tomó relacionado con esta autorización.

____________________                                  _________________

Firma del Recipiente                                                Fecha

_____________________________                  _________________

Firma del Representante del Estado                            Fecha

______________________________________________

Nombre en Imprenta de Representante del Estado

___________________________

# Teléfono Oficina Regional

3. Exhibit 3 – Connecticut Department Of Social Services Reimbursement City Of Norwich Authorization (W-650 TOWN)

W-650 STATE OF CONNECTICUT

(New 4/01) DEPARTMENT OF SOCIAL SERVICES

AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE TO THE STATE OF CONNECTICUT

A. INITIAL PAYMENT OR INITIAL POSTELIGIBILITY PAYMENT

Applicant's Name _______________________        Client ID No. _______________

Address _______________________________         Social Security No. ___________

City/Town _____________________________

The term State means the Connecticut Department of Social Services

What am I authorizing the State to do by signing this authorization if I checked the block called Initial Payment Only?

[] Initial Payment Only

If I am found eligible to receive Supplemental Security Income (SSI) benefits, I understand that I am authorizing the Commissioner of the Social Security Administration (SSA) to send to the State:

  • My first retroactive payment of SSI benefits, or

  • An amount equal to the amount of reimbursable General Assistance the Town gave to me, if law restricts the manner in which my SSI money can be released to me.

What am I authorizing the State to do by signing this authorization if I checked the block called Initial Posteligibility Payment Only?

[] Initial Posteligibility Payment Only

If I am found eligible to receive SSI benefits, I understand that I am authorizing the Commissioner of SSA to send to the State:

  • My first retroactive posteligibility payment of Supplemental Security Income (SSI) benefits, or

  • An amount equal to the amount of reimbursable General Assistance the Town gave to me when law restricts the manner in which my SSI money can be released to me.

How will the Town be paid for the reimbursable General Assistance it gave to me if I checked the block called Initial Payment Only?

If I am found eligible to receive SSI money, SSA will send my first retroactive SSI payment to the State or an amount equal to the amount of reimbursable General Assistance the Town gave to me when law restricts the manner in which my SSI money can be released to me. The State may:

  • Deduct from my first retroactive SSI payment the sum of all reimbursable Town General Assistance benefits made to, or on behalf of, me by the Town in situations when law does not restrict the manner in which my SSI money can be released to me, or

    • THIS INFORMATION IS AVAILABLE IN ALTERNATE FORMATS. PHONE (800) 842-1508 OR TDD/TTY (800) 842-4524.

  • Have SSA send it an amount equal to the amount of reimbursable General Assistance the Town gave to me when law restricts the manner in which my SSI money can be released to me, for months beginning with:

    • The first month for which I am eligible to receive an SSI payment and ending with the month my SSI payment begins, or

    • The following month if the Town cannot promptly stop making its last General Assistance payment to me.

The Town cannot be reimbursed for assistance it gave to me if that assistance was financed wholly or partly from Federal dollars.

How will the Town be paid for the reimbursable General Assistance it gave to me if I checked the block called Initial Posteligibility Payment Only?

If I am found eligible to receive SSI money, SSA will send my first retroactive posteligibility SSI payment to the State or an amount equal to the amount of reimbursable General Assistance the Town gave to me when law restricts the manner in which my SSI money can be released to me. The State may:

  • Deduct from my first retroactive posteligibility SSI payment the sum of all reimbursable Town General Assistance benefits made to, or on behalf of, me by the Town in situations when law does not restrict the manner in which my SSI money can be released to me, or

  • Have SSA send it an amount equal to the amount of reimbursable General Assistance the Town gave to me when law restricts the manner in which my SSI money can be released to me, for months beginning with:

    • The first day of the month in which my SSI payments resume following a period of suspension or termination and ending with, and including the month my SSI payments resume, or

    • The following month if the Town cannot promptly stop making its last General Assistance payment to me.

The Town cannot be reimbursed for assistance it gave to me if that assistance was financed wholly or partly from Federal dollars.

Can the State use this authorization for an Initial Payment of SSI benefits and an Initial Posteligibility Payment of SSI benefits?

No, I am authorizing the State to use this form for only one payment event. If both payment blocks are checked, this form is not binding on the State or me. If both blocks are checked, the Town and I must sign a new form with only one of the payment blocks checked.

Does this authorization serve as a protective filing for SSI benefits?

Yes, if I checked the Initial Payment Block, signing this form serves as a signed statement of my intention to claim SSI benefits if I have not filed an SSI application as of the date this authorization is received by the State. My eligibility for SSI benefits may begin as early as the date I sign this form if I file an application at a Social Security office for SSI benefits within 60 days after that date. This form also serves as a notice from SSA that I have sixty days from the date the State receives this form to file for SSI benefits. However, If I do not file an application for SSI benefits at a Social Security office within 60 days after that date, then I understand that I cancel my intention to claim SSI benefits and this authorization no longer protects my filing date for SSI.

How long is this authorization binding on the State and me if I checked the Initial Payment Block?

If I checked the Initial Payment Block, this authorization is binding on the State and me for one calendar year beginning with the date the State received it. If the Town does not notify SSA within thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the State or me. Also, this form must be signed and dated by both a Town representative and me to be a valid agreement that authorizes the State to receive interim assistance reimbursement from my SSI payments. However, if I have already applied for SSI before the State received this authorization, or I apply for SSI within one calendar year of the date described above, or I file a timely request for an administrative or judicial review within the time permitted under SSA's regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:

  • SSA makes the initial SSI payment on my initial claim; or

  • SSA makes a final determination on my claim; or

  • The State and I both agree to terminate this authorization.

How long is this authorization binding on the State and me if I checked the Initial Posteligibility Payment Block?

If I checked the Initial Posteligibility Payment Block, this authorization is binding on me and the State for one calendar year beginning with the date the State received it. If the Town does not notify SSA within thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the State or me. Also, this form must be signed and dated by both a Town representative and me to be a valid Agreement that authorizes the Town to receive interim assistance reimbursement from my SSI payments.

However, if I file a timely request for an administrative or judicial review within the time permitted under SSA"s regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:

  • SSA makes the initial SSI posteligibility payment following a suspension or termination of my SSI benefits; or

  • SSA makes a final determination on my appeal; or

  • The State and I both agree to terminate this authorization.

What rights and appeals are available to me under this authorization?

The State is required to:

  1. Pay to me any balance due from the retroactive SSI payment within 10 working days of the receipt of my SSI payment.

  2. Give me written notice explaining:

    • How much SSA repaid the Town for interim assistance it gave to me;

    • The balance, if any, due me unless the Social Security Act requires SSA to pay me such balance. (In such an event, SSA will notify me of the manner in which the balance will be paid to me.); and

    • That I will have an opportunity for a hearing with the State if I disagree with it's actions regarding repayment of interim assistance or any action it took regarding this authorization.

___________________                                           ___________________

Signature of Recipient                                                  Date

_________________________________                   ___________________

Signature of Town Representative                                 Date

4. Exhibit 4 – Connecticut Department Of Social Services Reimbursement City Of Norwich Authorization (W-650S, Spanish Version Town)

W-650S ESTADO DE CONNECTICUT

(New 4/01) DEPARTAMENTO DE SERVICIOS SOCIALES

AUTORIZACION DE REEMBOLSO DE ASISTENCIA INTERINA AL ESTADO DE CONNECTICUT

A. PAGO INICIAL O PAGO INICIAL POST-ELEGIBILIDAD

Nombre del Solicitante ___________________         No. AU _______________________

Dirección _____________________________         No. Seguro Social _______________

Ciudad/Pueblo __________________________

El término “Estado” significa el Departamento de Servicios Sociales de Connecticut.

¿Qué yo estoy autorizando al Estado a hacer si firmo esta autorización si yo marco el bloque llamado Pago Inicial solamente?

[] Pago Inicial Solamente

Si yo soy encontrado elegible a recibir beneficios de Ingreso de Seguridad Suplementario (SSI), Yo entiendo que yo autorizo al Comisionado de la Administración del Seguro Social (SSA) a enviar al Estado:

  • Mi primer pago retroactivo de beneficios del SSI, o

  • Una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió, si la ley restringe la manera en la cual mi dinero del SSI puede ser relevado a mi.

¿Qué yo estoy autorizando al Estado a hacer si firmo esta autorización si yo marco el bloque llamado Pago Inicial Post-elegibilidad Solamente?

[] Pago Inicial Post-elegibilidad Solamente

Si yo soy encontrado elegible a recibir beneficios de SSI, Yo entiendo que yo autorizo al Comisionado de SSA a enviar al Estado:

  • Mi primer pago retroactivo de post-elegibilidad de beneficios de Ingreso de Seguridad Suplementario (SSI), o

  • Una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió, si la ley restringe la manera en la cual mi dinero del SSI puede ser relevado a mi.

¿Cómo será pagado el Pueblo por la Asistencia General reembolsable dado a mí si yo marco el bloque llamado Pago Inicial solamente?

Si yo soy encontrado elegible a recibir dinero de SSI, el SSA enviará mi primer retroactivo de pago de SSI al Estado o una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mi. El Estado puede:

  • Deducir de mi primer pago retroactivo de SSI la suma de todos los beneficios de Asistencia General del Pueblo reembolsables hechos a, o a favor de mí por el Pueblo en situaciones donde la ley no restringe la manera en la cual mi dinero de SSI puede ser relevado a mi; o

    • ESTA INFORMACION ESTA DISPONIBLE EN FORMATOS ALTERNOS. TELEFONO (800) 842-1508 O TDD/TTY (800) 842-4524.

  • Hacer SSA enviar una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí, por meses comenzando con:

    • El primer mes por el cual yo soy elegible a recibir un pago de SSI y terminando con el mes que mi pago de SSI comienza, o

    • El mes siguiente si el Pueblo no puede prontamente parar de hacer el último pago de Asistencia General a mi.

El Pueblo no puede ser reembolsado por asistencia dada a mí si esa asistencia fue financiada totalmente o parcialmente de dólares federales.

¿Cómo será pagado el Pueblo por la Asistencia General reembolsable dado a mí si yo marco el bloque llamado Pago Inicial Post-eligibilidad Solamente?

Si yo soy encontrado elegible a recibir dinero de SSI, el SSA enviará mi primer retroactivo de pago post-eligibilidad de SSI al Estado o una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí. El Estado puede:

  • Deducir de mi primer pago post-eligibilidad retroactivo de SSI la suma de todos los beneficios de Asistencia General del Pueblo reembolsables hechos a, o a favor de mí por el Pueblo en situaciones donde la ley no restringe la manera en la cual mi dinero de SSI puede ser relevado a mi; o

  • Hacer SSA enviar una cantidad igual a la cantidad de Asistencia General reembolsable que el Pueblo me dió cuando la ley restringe la manera en la cual mi dinero de SSI puede ser relevado a mí, por meses comenzando con:

    • El primer día del mes en el cual mis pagos de SSI se reanudan siguiendo un periodo de suspensión o terminación y terminando con, e incluyendo el mes que mis pagos de SSI se reanudan, o

    • El mes siguiente si el Pueblo no puede prontamente parar de hacer el último pago de Asistencia General a mí.

El Pueblo no puede ser reembolsado por asistencia dada a mí si esa asistencia fue financiada totalmente o parcialmente de dólares federales.

¿Puede el Estado usar esta autorización para un Pago Inicial de beneficios de SSI y un Pago Inicial Post –Eligibilidad de beneficios de SSI?

No. Yo estoy autorizando al Estado a usar esta forma para solamente un pago. Si ambos bloques de pago son marcados esta forma no es ligado en el Estado o en mí. Si ambos bloques son marcados, el Pueblo y yo debemos firmar una nueva forma con solamente uno de los bloques de pago marcado.

¿Sirve esta autorización como una llenada protectiva para beneficios de SSI?

Si, si yo he marcado el Bloque de Pago Inicial, firmando esta forma sirve como una declaración firmada de mi intención a reclamar beneficios de SSI si yo no he llenado una aplicación de SSI para la fecha que esta autorización es recibida por el Estado. Mi elegibilidad para beneficios de SSI puede comenzar tan pronto como la fecha cuando yo firmo esta forma si yo lleno una aplicación en la oficina de Seguro Social para beneficios de SSI dentro de 60 días después de esa fecha. Esta forma también sirve como un aviso de SSA que yo tengo sesenta días de la fecha que el Estado recibió esta forma para llenar por beneficios de SSI. Sin embargo, si yo no lleno una aplicación para beneficios de SSI en la oficina del Seguro Social dentro de 60 días antes de esta fecha, entonces yo entiendo que yo cancelo mi intención a reclamar beneficios de SSI y esta autorización no protege más mi fecha de llenar para SSI.

¿Por cuánto es esta autorización ligada en el Estado y conmigo si yo marco el Bloque de Pago Inicial?

Si yo he marcado el Bloque de Pago Inicial, esta autorización es ligada con el Estado y conmigo por un año comenzando con la fecha que es recibido en el Estado. Si el Pueblo no notifica al SSA dentro de (30) días calendarios de la fecha que yo firmo esta autorización, la autorización no está ligada con el Estado o conmigo. También, esta forma debe ser firmada y fechada por ambos un representativo del Pueblo y yo para ser un acuerdo válido que autoriza al Estado a recibir reembolso de asistencia interina de un representativo del Estado y yo para ser un acuerdo válido que autoriza al Estado a recibir reembolso de asistencia interina de mis pagos del SSI. Sin embargo, si yo ya he aplicado para SSI antes de que el Estado recibió esta autorización, o yo aplico por SSI dentro de un año calendario de la fecha descrita arriba, o yo lleno una petición a tiempo para una revisión administrativa o judicial dentro del tiempo permitido bajo las regulaciones de SSA, esta autorización se mantendrá en efecto, aun sí después de un periodo de un año calendario, hasta tal tiempo como:

  • SSA hace el pago inicial de SSI en mi reclamación inicial; o

  • SSA hace una determinación final en mi reclamación; o

  • El Estado y yo ambos estamos de acuerdo a terminar esta autorización.

¿Por cuánto es esta autorización ligada en el Estado y conmigo si yo marco el Bloque de Pago Inicial Post-elegibilidad?

Si yo he marcado el Bloque de Pago Inicial Post-elegibilidad, esta autorización es ligada con el Estado y conmigo por un año calendario comenzando con la fecha que es recibido en el Estado. Si el Pueblo no notifica al SSA dentro de (30) días calendarios de la fecha que yo firmo esta autorización, la autorización no está ligada con el Estado o conmigo. También, esta forma debe ser firmada y fechada por ambos un representativo del Pueblo y yo para ser un acuerdo válido que autoriza al Pueblo a recibir reembolso de asistencia interina de mis pagos del SSI.

Sin embargo, si yo lleno una petición a tiempo para una revisión administrativa o judicial dentro del tiempo permitido bajo las regulaciones de SSA, esta autorización se mantendrá en efecto, aun sí después de un periodo de un año calendario, hasta tal tiempo como:

  • SSA hace el pago inicial post-elegibilidad de SSI siguiendo una suspensión o terminación de mis beneficios de SSI; o

  • SSA hace una determinación final en mi apelación; o

  • El Estado y yo ambos estamos de acuerdo a terminar esta autorización.

¿Qué derechos y apelaciones están disponibles para mi bajo esta autorización?

El Estado es requerido a:

  1. Pagarme cualquier balance debido a retroactivo de Pago de SSI dentro de 10 días laborables del recibo de mi pago de SSI.

  2. Darme un aviso por escrito explicando:

    • Cuánto SSA re-pagó al Pueblo por asistencia interina dada a mi;

    • El balance, si hay, debido a mi a menos que el Decreto del Seguro Social requiera que SSA me pague tal balance. (En tal evento, SSA me notificará la manera en la cual el balance será pagado a mi.); y

    • Que yo tendré una oportunidad para una audiencia con el Estado si yo no estoy de acuerdo con estas acciones relacionadas a re-pagó de asistencia interina o cualquier acción que tomó relacionado con esta autorización.

_____________________                                             ____________________

Firma del Recipiente                                                            Fecha

___________________________________                    _____________________

Firma del Representante del Estado                                        Fecha

______________________________________________

Nombre en Imprenta de Representante del Estado

____________________________

# Teléfono Oficina Regional

5. Exhibit 5 – Connecticut Notice To Claimant When Money Is Due.

D.I.M. MIDDLEFIELD
666 REVELATION ROAD
MIDDLEFIELD CT 06401

STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICE

                                                    Date:

                                                    Client ID:

                                                    Worker:

                                                    Phone:

1030 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare. After we paid back the city or town, there was $ left. We issued a check to you in this amount.

This check was used as repayment of the following amounts you received from the city or town.

Town                                           Amount

Total                                         ________

You can request a hearing if you disagree with this decision. Please read the last two pages of this notice for more information about your hearing rights.

1030 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare. After we paid back the city or town, there was $ left. We issued a check to you in this amount.

This check was used as repayment of the following amounts you received from the city or town.

Town                                           Amount

TOTAL                                     ________

You can request a hearing if you disagree with this decision. Please read the last two pages of this notice for more information about your hearing rights.

1030 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare. After we paid back the city or town, there was $ left. We issued a check to you in this amount.

This check was used as repayment of the following amounts you received from the city or town.

Town                                           Amount

TOTAL                                     ________

You can request a hearing if you disagree with this decision. Please read the las two pages of this notice for more information about your hearing rights.

INQUIRY                     NOTICE CONTENT – NCON                   NCON

                                                                                                  003 MORE

                                                Client ID

DSS – SGA              0.00

                             _____

Total                     $00.00

You can request a hearing if you disagree with this decision. Please read the las two pages of this notice for more information about your hearing rights.

6. Exhibit 6 – Connecticut Notice To Claimant When No Money Is Due.

D.I.M. MIDDLEFIELD
666 REVELATION ROAD
MIDDLEFIELD CT 06401

STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICE

                                                    Date:

                                                    Client ID:

                                                    Worker:

                                                    Phone:

1029 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare.

We used the entire SSI check to pay back the city or town, so there is nothing left to send you. This check was used as repayment of the following amounts you received from the city or town.

Town                                           Amount

Total                                         ________

You can request a hearing if you disagree with this decision. Please read the last two pages of this notice for more information about your hearing rights.

1029 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare.

We used the entire SSI check to pay back the city or town, so there is nothing left to send you. This check was used as repayment of the following amounts you received from the city or town.

Town                                           Amount

TOTAL                                     ________

You can request a hearing if you disagree with this decision. Please read the last two pages of this notice for more information about your hearing rights.

1029 – Information About Your Retroactive SSI Check

The Social Security Administration sent us a Supplemental Security Income (SSI) check on your behalf. The amount of this check was $ . You agreed to have this check paid to us as repayment of your city or town welfare.

We used the entire SSI check to pay back the city or town, so there is nothing left to send you. This check was used as repayment of the following amounts you received from the city or town.

INQUIRY                     NOTICE