California Form Mc 194 PDF Details

Ensuring individuals have access to vital services like Food Stamps, Cash Aid, or Medi-Cal in California often hinges on the accuracy and existence of a Social Security Number (SSN). The California MC 194 form serves as a critical link between the Department of Health Care Services and the Social Security Administration (SSA). This form helps in identifying discrepancies or the absence of an SSN for applicants or recipients of these services. Crafted to facilitate communication, it guides County Welfare Departments (CWD) in submitting requests to the SSA, thereby ensuring that every individual's SSN is accurately recorded or corrected as necessary. Part I of the form is filled out by the CWD, detailing the necessary action, such as verification or correction of SSN details, or addressing cases of duplicate SSNs. This section also includes instructions for recipients on how to proceed, emphasizing the importance of providing verification for any changes. The SSA responds in Part II, noting the outcome of the referral. This streamlined process underscores the importance of collaboration between state health services and federal administration to uphold public law mandates—ensuring all applicants or recipients of state assistance have a valid SSN, a prerequisite for accessing these essential services.

QuestionAnswer
Form NameCalifornia Form Mc 194
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesssn, 95a, ssa, ar3a

Form Preview Example

State of California – Health and Human Services Agency

Department of Health Care Services

 

SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE

Instructions:

 

 

• To CWD:

Please complete Part I. Retain original for your records, copy for recipient/SSA. Client must take this form to SSA.

•To Recipients: Read the back of this form. Take the necessary documentation to the Social Security Administration listed below in Part I B.

• To SSA:

This form is a request for the action noted in Part I C. Please complete Part II of this form and distribute as noted in Part I A.

 

If you have any questions, the eligibility worker’s name and phone number are provided.

 

 

 

 

 

PART I: TO BE COMPLETED BY THE COUNTY WELFARE DEPARTMENT

 

 

A.Please enter the complete county welfare office name and address within the brackets provided.

SSA, after completion:

☐ FAX To:

☐ Mail this form to the county welfare office.

☐ Return this form to the recipient to be returned to CWD.

B.Social Security Office Information

Name of SSA District/Regional Office

Address (number and street)

City

State

ZIP Code

 

 

 

D.Applicant/Recipient Information

Recipient’s name (last, first, middle initial)

Date of birth (month/day/year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex (M or F)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

County ID per MEDS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recipient’s SSN (if applicable)

 

 

 

Case name

E.CWO Information

Name of Eligibility Worker

C. If the bearer of this form is either an applicant or a recipient of Food Stamps, Cash Aid, or Medi-Cal, the following service is required:

 

 

 

 

 

 

Original SSN card

 

 

 

 

 

 

 

 

☐

 

 

 

 

 

 

 

 

 

 

 

 

Duplicate SSN card

 

 

SSN#:

 

 

 

 

 

☐

 

 

 

 

 

 

 

 

 

 

 

 

Info on SSA’s Data Bases (Numident, Title II, Title XVI, and

☐

 

 

 

 

 

 

 

Medicare) needs to be verified.

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

DOB

 

 

Sex

 

 

 

 

 

 

 

☐

 

☐

☐

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ Info on SSA’s Data Bases (Numident, Title II, Title XVI, and

Medicare) needs to be corrected.

☐ Name ☐ DOB ☐ Sex

Note: Recipient must provide verification of change.

☐ Recipient has been assigned two SSNs. Please take action to delete all but one.

☐ Two recipients appear to have been assigned the same SSN.

Please verify correct number for recipient from Numident File.

F. Comments

Date form completed

E.W. Worker

E.W. phone number

PART II: TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION DISTRICT/REGIONAL OFFICE

A. Date Received

 

B. Result of Referral

 

 

 

☐

 

Recipient has completed an SSN application (including Form

 

 

 

 

 

SS-5 and other proof) and application is being processed.

C. Comments

 

 

 

 

 

 

 

☐

 

Insufficient Identification

 

 

 

 

 

 

☐

 

SSN application is not being processed. (Explain)

 

 

 

 

 

 

 

 

 

 

 

 

☐

 

Other (Explain in Comments Section.)

 

 

 

 

 

 

 

 

 

D. SSA Representative – print name

Signature

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

MC 194 (07/12)

SSA REFERRAL INFORMATION SHEET

(For Medi-Cal, Food Stamp, and CalWORKs Recipients)

YOU MUST CONTACT SOCIAL SECURITY

Public Law requires that each person who applies for or receives full-scope Medi-Cal, Food Stamps, or California Work Opportunity and Responsibility to Kids must have or apply for a social security number. For the applicant/ recipient noted on the reverse side, either (1) the Social Security Administration does not have a social security number on file, or (2) the information provided by the Social Security Administration and the information provided to the eligibility worker do not agree. To correct this situation, you must contact the Social Security Office indicated on the reverse side of this referral form. DO NOT MAIL THESE FORMS TO THEM.

NOTE: Age, citizenship or alien status, and identity must all be documented. One of the identification documents must be a birth or baptismal certificate established BEFORE age 5. If one is not obtainable, refer to Column A for acceptable substitutes. In addition, if the applicant/recipient is a U.S. citizen born outside of the U.S. or an alien, one of the items listed in Column B must be presented.

Column A

1.Evidence of Age/Citizenship

•School records

•Church records

•Census records (state or federal)

•Insurance policy

•Marriage records

•Draft card

•U.S. passport

•Other records indicating applicant’s age or date and place of birth

2.Evidence of Identity

•Driver’s license

•State identification card

•Voter’s registration

•School records

•Health records (doctor’s, hospital’s, etc.)

•Any other document which shows applicant’s signature, photograph, or description

Column B

1.If you are now a U.S. citizen born outside the U.S., take one of the following items in addition to the item(s) required in Column A:

•U.S. citizen identity card

•U.S. passport

•Naturalization certificate

•Certificate of citizenship

•Consular report of birth

•Form I-179 (U.S. citizen card)

•Form I-197 (U.S. citizen resident card)

2.If you are an alien, take one of the following items in addition to the item(s) listed in Column A:

•Form I-151 or I-551 (Alien Registration Receipt Card)

•Form AR3a, I-94, I-95a, I-84, I-85, I-86, or SW-434

•Letters from Immigration and Naturalization Service showing alien status

If you have a question concerning the two identification documents which you must take to the Social Security Office, please contact the Social Security Office.

MC 194 (07/12)

How to Edit California Form Mc 194 Online for Free

mc 194 social administration can be filled out easily. Just make use of FormsPal PDF tool to do the job promptly. The tool is consistently improved by us, acquiring useful features and growing to be even more convenient. By taking a few simple steps, it is possible to start your PDF editing:

Step 1: Click on the "Get Form" button above. It will open up our tool so that you can start filling in your form.

Step 2: With our state-of-the-art PDF editor, you'll be able to accomplish more than just fill in forms. Express yourself and make your docs look sublime with custom text incorporated, or optimize the original content to excellence - all comes with an ability to incorporate almost any pictures and sign the PDF off.

For you to complete this document, make certain you provide the right details in every field:

1. Complete the mc 194 social administration with a number of necessary fields. Gather all the required information and make certain there is nothing left out!

social security referral form conclusion process detailed (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - F Comments, E CWO Information Name of, Date form completed, EW Worker, EW phone number, PART II TO BE COMPLETED BY THE, A Date Received, C Comments, D SSA Representative print name, MC , B Result of Referral, Recipient has completed an SSN, SS and other proof and application, Insufficient Identification, and SSN application is not being with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part number 2 of completing social security referral form

It's simple to make an error while completing the EW Worker, and so you'll want to take another look before you'll finalize the form.

Step 3: Make certain your details are correct and then press "Done" to proceed further. Join us today and immediately use mc 194 social administration, ready for download. All changes made by you are saved , helping you to edit the document at a later point if required. At FormsPal, we do everything we can to be sure that your information is maintained secure.

California Form Mc 194 isn’t the one you’re looking for?

Related Documents