Mc 194 - Social Security Administration Referral Notice
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1
2Department of Health Care Services
State of California—Health and Human Services Agency
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 Office 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:
Mail this form to the county welfare office.
Return this form to the recipient to be
returned to CWD.
C. The bearer of this form is an applicant for, or recipient of, Food
B.
Social
Security Office Information
Stamps, Cash Aid, or Medi-Cal. The following service is required:
Name of SSA District/Regional Office
Original SSN card
Address (number and street)
Duplicate SSN card
SSN: ______________________
City
State
ZIP code
Info on SSA’s Numident File needs to be verified.
Name
DOB
Sex
D.
Appl
icant/Recipient Information
Recipient’s name (last, first, middle initial)
Info on SSA’s Numident File needs to be corrected.
Name
DOB
Sex
Date of birth (month/day/year)
Sex (M or F)
Note:
Recip
ient must provide verification of change.
County ID per MEDS
Recipient has been assigned two SSNs.
Ple
ase take action
X
to delete all but one.
Recipient’s SSN (if applicable)
Two recipients appear to have been assigned the same SSN.
Please verify correct number for recipient from Numident File.
Case name
E.
CWO
Information
Name of Eligibility Worker
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
1.
Recipient has completed an SSN application (including
C. Comments
Form SS-5 and other proof) and application is being
processed.
2.
Insufficient ID.
3.
SSN application is not being processed.
(Explai
n.)
4.
Other.
(Ex
plain.)
D. SSA Representative—print name
Signature
Telephone number
MC 194 (05/07)
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