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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
APPLICANT CERTIFICATION OF CONTACT WITH SSA TO CHANGE
STATUS FROM INSTITUTIONAL CARE TO A HOME SETTING
This is to certify that I have notified the Social Security Administration
on ______________ that I will be discharged from ______________________ to
(date) (facility name)
live in my own home located at _______________________________________.
(address)
Signature of applicant: _____________________________________
Printed name of applicant: __________________________________
Social Security Number: ____________________________________
Date: _____________________
SOC 810 (2/02)
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