CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERIVCES AGENCY
REQUEST FOR CONDITIONAL CAPI AFTER NATURALIZATION PENDING SSI/SSP
ELIGIBLITY DETERMINATION
SOCIAL SECURITY NO.
NAME
I understand that on the date I naturalized, I became ineligible for CAPI benefits; however, I would like
to accept conditional CAPI while my Supplementary Security Income/State Supplementary Payment
(SSI/SSP) eligibility is being determined.
I also understand that in order to continue to receive these benefits, I or my authorized representative,
must contact (by phone, mail, or in person) the Social Security Administration (SSA) Office as soon as
possible, but not more than 30 days after the date of this document, to apply for SSI/SSP, and fully com-
ply with the SSI/SSP application and appeal process, which includes responding to any SSA requests
for information and/or documents in a timely manner.
I understand that these benefits will be terminated if I become ineligible for CAPI for any reason before
the SSI/SSP application and appeal process is completed, or, if at any time, I fail to fully comply with the
SSI/SSP application and appeal process.
I acknowledge that I cannot receive duplicate payments and will have to repay any CAPI payments dis-
bursed to me in any month for which I also receive any SSI/SSP payments. I also understand that if I
become ineligible for CAPI before the completion of the SSI/SSP application and appeal process due
to my own failure to comply with the SSI/SSP application and appeal process, I will have to repay all
CAPI payments I receive after this date.
DATE
YOUR SIGNATURE
WITNESS, IF SIGNED WITH AN “X”
DATE
DATE
SIGNATURE OF AN INTERPRETER OR PERSON COMPLETING FORM ON YOUR BEHALF
TELEPHONE NUMBER
RELATIONSHIP TO APPLICANT
(
)
SOC 830 (1/08)
1
