Application for SSI/SSP
The following forms are required and MUST be completed when assisting a client to apply for SSI:
“Referral To/From Social Security” (SCD 169)
As a condition of eligibility for GA, a “Referral To/From Social Security” (SCD 169) must be completed for those IAR applicants/recipients who:
- Are required to apply for SSI,
- Have been denied SSI and need to reapply or have reapplied, and/or
- State they have applied for SSI on their own.
"Agreement to Reimburse - Sponsor" (SCD 355 S/A)
All applicants, spouses (if residing with the spouse), and legal guardians applying and/or receiving GA benefits, and who have been sponsored into the United States must have their sponsors sign the SCD 355 S/A in black ink prior to receipt of aid.
The SCD 355 S/A is an agreement to make reimbursement of all aid and assistance rendered to the client or immediate family, whether past, present, or future, and/or agree to make reimbursement for costs of administration and/or confinement under penal Code Section 1208. The signee or co-signee waives the limitation of any statute for the presentation of any claim for the repayment of relief, care, and maintenance and/or medical aid owing, or to come due in the future. Also, it agrees that all monies so paid secured by a lien on all property that is own or acquired or in the event of coming into possession of any funds or property of any kind, or if at the time of death the signee leaves any estate whatsoever, an agreement is made to repay for all monies so paid, as a preferred claim.
This reimbursement agreement is recorded with the County Recorder and is intended to ensure repayment of aid. It creates a lien against all current and future real property for which the signer or co-signer holds title in Santa Clara County.
“Authorization for Reimbursement of Interim Assistance Initial Payment or Initial Posteligibility Payment” (SSP 14)
The SSP 14 is required for GA IA cases to obtain reimbursement as of June 2008. The purpose of obtaining a signed SSP 14 is to recover from an individual's Initial retroactive or Posteligibility SSI payment. Interim Assistance is the amount of aid the county provides the individual for meeting basic needs while the individual's SSI application is pending or during the time the SSI benefits are suspended or terminated and subsequently reinstated. Therefore, it is vital that an SSP 14 be obtained and a copy is retained in Imaging. Without a current copy the County cannot recoup the IAR.
Note: The SSP 14 must be obtained from the DEBS Forms Library.
Related Topics
"Automated" Interim Assistance Reimbursement (IAR) County
Social Security Administration's SSI eIAR Web Application