Ssp 14 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICES

AUTHORIZATION FOR REIMBURSEMENT OF INTERIM ASSISTANCE

INITIAL CLAIM OR POSTELIGIBILITY CASE

NAME		SOCIAL SECURITY NUMBER
ADDRESS	CITY/TOWN	ZIP CODE
COUNTY IA AGENCY		GR CODE

For the purpose of this Authorization Form:

The term “State” means the California county interim assistance (IA) agency (s) that the California Department of Social Services has an interim assistance reimbursement agreement with and that paid you public assistance.

The term “SSI/SSP benefits” means “Supplemental Security Income/State Supplementary Payment” benefits under Title XVI of the Social Security Act.

What actions am I authorizing when I sign this authorization and I check the “Initial Claim Only” block?

■Initial Claim Only

You are authorizing the Commissioner of the Social Security Administration (SSA) to reimburse the State for some or all of the money the State gives you while SSA decides if you are eligible to receive SSI/SSP benefits. If you become eligible, SSA pays the State from the retroactive SSI/SSP benefits due you. The reimbursement covers the time from the first month you are eligible to receive SSI/SSP benefits through the first month your monthly SSI/SSP benefit begins.

If the State cannot stop the last payment made to you, SSA can reimburse the State for this additional payment amount.

What actions am I authorizing when I sign this authorization and I check the “Posteligibility Case Only” block?

You are authorizing the Commissioner of the Social Security Administration (SSA) to reimburse the State for some or all of the money the State gives you while SSA decides if your SSI/SSP benefits can be reinstated after being terminated or suspended. If your SSI/SSP benefits resume, SSA pays the State from the retroactive SSI/SSP benefits due you. The reimbursement overs the time from the day of the month the reinstatement is effective through the first month your monthly SSI/SSP benefit resumes.

If the State cannot stop the last payment made to you, SSA can reimburse the State for this additional payment amount.

How can the State use this form when blocks for initial claims and posteligibility cases are part of the form?

The State can use this form for one case situation at a time, either an initial claim or a posteligibility case. If both blocks are checked the form is not valid. You and the State must sign and date a new form with only one block checked.

What kind of State payment qualifies for reimbursement by SSA?

SSA can reimburse a State for a payment that is paid only from State or local funds. The State cannot be reimbursed for payments made wholly or partially from Federal funds.

How does SSA determine how much of my SSI/SSP money to pay the State?

SSA decides the amount of payment based on two considerations. First, SSA looks at the amount of money claimed by the State, and second, SSA looks at the amount of your retroactive SSI/SSP money available to pay the State. SSA can reimburse the State for a payment made in a month only when you receive a State payment and an SSI/SSP payment for the same month. SSA will not pay the State more money than you have for the SSI/SSP retroactive period.

How long is this authorization effective for the State and me if I checked the “Initial Claims Only” block?

This authorization is in effect for you and the State for twelve (12) months. The 12 months begin with the date SSA receives the authorization from the State and end 12 months later. However, for a State using an electronic system, the 12 months begin with the date the State notifies SSA through an electronic system that the State has received the authorization and end 12 months later. You and a State representative must sign and date the authorization for the authorization to be valid.

Exceptions apply to this rule. The State must send SSA the authorization within a certain time frame. SSA must receive the form within 30 calendar days of the date you signed the authorization. If the form is late, SSA will not accept the form as a valid authorization. For the State using an electronic system, SSA must receive the authorization information within 30 calendar days of the state matching your SSI record with your state record. If the information is late, SSA will not accept the information sent by the State. SSA will not pay any of your retroactive SSI/SSP benefits to the State. SSA will send you any SSI/SSP money that may be due you, based on SSA’s regular payment rules.

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Can the authorization stay effective longer than the 12-month period? Can the authorization end before or after the 12-month period ends?

The authorization can stay effective longer than the 12-month period, if you

•apply for SSI/SSP benefits before the State has the authorization form, or

•apply within the 12-month period the authorization is effective, or

•file a valid appeal of SSA’s determination on your initial claim.

The period of the authorization can end before the 12-month period ends, or end after the 12-month period ends when any of these actions take place:

•SSA makes the first SSI/SSP payment on your initial claim; or

•SSA makes a final determination on your claim; or

•the State and you agree to terminate this authorization.

The authorization period will end with the day of the month any of these actions take place.

How long is this authorization effective for the State and me if I check the “Posteligibility Case Only” block?

This authorization is in effect for you and the State for twelve (12) months. The 12 months begin with the date SSA receives the authorization from the State and end 12 months later. However, for a State using an electronic system, the 12 months begin with the date the State notifies SSA through an electronic system that the State has received the authorization and end 12 months later. You and a State representative must sign and date the authorization for the authorization to be valid.

Exceptions apply to this rule. The State must send SSA the authorization within a certain time frame. SSA must receive the form within 30 calendar days of the date you signed the authorization. If the form is late, SSA will not accept the form as a valid authorization. For a State using an electronic system, SSA must receive the authorization information within 30 calendar days of the State matching your SSI record with your State record. If the information is late, SSA will not accept the information sent by the State. SSA will not pay any of your retroactive SSI/SSP benefits to the State. SSA will send you any SSI/SSP money that may be due you, based on SSA’s regular payment rules.

Can the authorization stay effective longer than the 12-month period? Can the authorization end before or after the 12-month period ends?

The authorization can stay in effect longer than the 12-month period if you file a valid appeal. You must file your appeal within the time frame SSA requires.

The period of the authorization can end before the 12-month period ends, or can end after the 12-month period ends when any of these actions take place:

•SSA makes the first SSI/SSP payment on your posteligibility case after a period of suspension or termination; or

•SSA makes a final determination on your appeal; or

•the State and you agree to terminate this authorization.

The authorization period will end with the day of the month any of these actions take place.

Can SSA use this authorization form to protect my filing date for SSI/SSP benefits?

SSA can use this form to protect your filing date if you checked the “Initial Claims Only” block. When you sign this form, you are saying that you have the intention of filing for SSI/SSP benefits if you have not already applied for benefits.

You have sixty (60) days from the date the State receives this form to file for SSI/SSP benefits. Your eligibility to receive SSI/SSP benefits can be as early as the date you sign this authorization if you file within the 60-day time period. If you file for SSI/SSP benefits after the 60-day time period, this form will not protect your filing date. Your filing date will be later than the date you sign this form.

How do I appeal the State’s decision if I do not agree with the decision?

You can disagree with a decision the State made during the reimbursement process. You will receive the State notice telling you how to appeal the decision. You cannot appeal to SSA if you disagree with any State decision.

Within 10 working days after the State receives the reimbursement money from SSA, the State must send you a notice. The notice will tell you three things: (1) the amount of the payments the State paid you; (2) that SSA will send you a letter explaining how SSA will pay the remaining SSI/SSP money (if any) due you, and (3) about your right to a hearing with the State, including how to request the State hearing.

If the applicant signs this application with a mark, the signature must have two witnesses who provide their signatures, addresses, and the dates they signed below.

WITNESSED BY:			WITNESSED BY:
ADDRESS (#, STREET):			ADDRESS (#, STREET):
CITY	STATE	ZIP	CITY	STATE	ZIP

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