Mc 194 Ca Form PDF Details

The MC 194 CA form serves as a crucial bridge in the communication between the various agencies responsible for welfare services and the Social Security Administration (SSA) in the State of California. It is designed to ensure that applicants or recipients of Food Stamps, Cash Aid, or Medi-Cal services have or apply for a Social Security number, which is a mandatory requirement. This form outlines a clear process, starting from the County Welfare Department (CWD) through to the final verification by the SSA. The form is divided into sections that guide the CWD on what information to fill out, instructions for the recipient on the documentation necessary to bring to the SSA, and a part for the SSA to complete regarding the outcome of the referral. It specifies the need for original or duplicate Social Security cards, the necessity to verify or correct information on SSA's databases, and addresses the issue of multiple Social Security numbers or shared numbers between recipients. Additionally, it includes an information sheet providing detailed guidance on the types of identification documents required when contacting the SSA. This document not only facilitates the accurate and efficient processing of essential public assistance applications but also underscores the importance of inter-agency cooperation in serving the public's needs.

QuestionAnswer
Form NameMc 194 Ca Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameschargar model mc 194, SSA, SSAs, California

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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 (05/07)

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2. Once this part is done, go to enter the suitable details in these - B Social Security Office, Recipients SSN if applicable Case, E CWO Information Name of, EW phone number, Info on SSAs Data Bases Numident, F Comments, PART II TO BE COMPLETED BY THE, A Date Received, CComments, B Result of Referral, Recipient has completed an SSN, Insufficient Identification, SSN application is not being, Other Explain in Comments Section, and D SSA Representative print name.

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