Vermont Department of Prevention, PATH 230
Assistance, Transition, and Health Access R 10/00
Authorization for Interim Assistance Reimbursement
(Initial SSI)
Applicant's Name_______________________________________________________
Address________________________________________________________________
Phone number _____________ Social Security# __________________________
If I am found eligible to receive Supplemental Security Income (SSI) benefits, I authorize
the Commissioner of the Social Security Administration (SSA) to send to the Vermont
Department of Prevention, Assistance, Transition, and Health Access (PATH) my first
retroactive payment of SSI benefits, or an amount equal to the amount of reimbursable
public assistance PATH paid to me, in the manner required by law.
PATH may reimburse itself from my first retroactive SSI payment the sum of all state
public assistance benefits PATH made to me or on behalf of me as follows: PATH will
determine the amount of its reimbursement by adding together each assistance payment
I received beginning with the first day of the month that I am found eligible for
an SSI payment and ending with the month my SSI payments began, not including assistance
financed wholly or in part by federal funds.
I understand that after making the deduction for reimbursement, PATH shall pay me
the balance, if any, within 10 days of receiving my first SSI payment. Along with
the payment of the balance, PATH will send me a written notice explaining the reimbursement
amount PATH kept, the balance PATH is paying to me, and my right to a fair hearing
before the Vermont Human Services Board if I disagree with any action PATH took regarding
my interim assistance reimbursement payment or this authorization.
I understand that this authorization is only binding on PATH or me if PATH notifies
SSA of it within 30 calendar days of the date I signed it. I understand it is effective
for one year from the date PATH receives the signed form from me. If I have already
filed for SSI, or I file for SSI within one year after signing this form, or I file
a timely request for administrative or judicial review under SSA's regulations, however,
this authorization will remain in effect until:
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•
SSA makes the initial SSI payment on my initial claim; or
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•
SSA makes a final determination on my claim; or
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•
PATH and I both agree to terminate this authorization.
I further understand that this signed authorization means that I have applied or I
intend to apply for SSI benefits to determine if I am eligible. I understand that
if I am found eligible for SSI benefits, my eligibility for SSI can begin as early
as the date I return this form to PATH, as long as I file the SSI application within
60 days of the date of signing the form.
I also understand that for this authorization to be binding on the state and me, it
must be signed and dated by both me and a representative of PATH.
_______________________________________ ______________________
Applicant's signature Date
_______________________________________ ________________________
Worker's signature and district office Date received
Distribution: white – SSA; yellow – PATH, Admin. Srvs; pink – applicant; gold – district
file