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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