Public Assistance Agency Information Request Form
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
SOCIAL SECURITY ADMINISTRATION
OMS NO 0960-0095
PUBLIC ASSISTANCE AGENCY INFORMATION REQUEST
This report is authorized by section 402(a) of the Social Security Act.
Requested Information cannot be provided without a submittal of this form
1. SOCIAL SECURITY WAGE EARNER INFORMATION
a. WAGE EARNER’S NAME
b. SEX
c. DATE OF
d. DATE OF
e. SOCIAL SECURITY NUMBER
f. CLAIM SYMBOL
BIRTH
DEATH
(If unknown see instructions)
□
MALE
□
FEMALE
(Mo. Day Yr)
(Mo. Day Yr.)
2. TO:
3. PUBLIC ASSISTANCE CLAIMANT INFORMATION
SOCIAL SECURITY ADMINISTRATION
a. CLAIMANT’S NAME
b. SOCIAL SECURITY NUMBER
c. DATE OF BIRTH
d. CASE NUMBER
(Mo. Day Yr)
e. ADDRESS (include ZIP Code)
f. TELEPHONE NO. (include area code)
g. RELATIONSHIP TO WAGE EARNER
4. PUBLIC ASSISTANCE AGENCY REQUEST
ٱYES
ٱNO
a. Is the requested information available on BENDEX, SDX, BUY-IN?
If no, explain
b.
Information is needed for
Dates
__________________
Program
Purpose:
Title IV
________________
Title XIX
______________ Entitlement _______________ Referral ______________
Title XVI ________________
Food Stamps ______________ Fraud
_______________ Other
______________
Title XVIII _________________
Other
______________ QA
_______________
c. Please complete the checked blocks for the individuals whose names, dates of birth and SSN are given below
FOR REQUESTING AGENCY USE
FOR SSA USE
SMI9
AMOUNT OF
NAME AND SOCIAL SECURITY
DATE OF BIRTH
TYPE OF
DATE OF
EFFECTIVE
PAYMENT
EFFECTIVE
BENEFIT
NUMBER OF BENEFICIARY
(
BENEFIT
ENTITLEMENT
DATES
STATUS
DATE
Mo. Day. Yr.)
Gross
Net
1.
SSN
2
SSN
3
SSN
4
SSN
d. OTHER
5. REMARKS (If additional space is needed use reverse of this sheet)
8. RETURN TO:
6. Signature of Requesting Official
Title
Date
7. Signature of SSA Official
Title
Date
NAME AND ADDRESS OF AGENCY (include ZIP Code)
FORM SSA-1610-U2 (2-82)
Attachment 2
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