STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA 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?
Posteligibility Case 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 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.
SSP 14 (9/10) PAGE 1 OF 2
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 ha
ve 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.
SIGNATURE OF INDIVIDUAL RECEIVING INTERIM ASSISTANCE DATE
SIGNATURE OF STATE REPRESENTATIVE DATE
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
S TATE
ZIP
CITY
S TATE
ZIP
SSP 14 (9/10)
PAGE 2 OF 2
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