STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF ACTION AND
RIGHT TO REQUEST A STATE HEARING
ON INTERIM ASSISTANCE
State No.:
County No.:
Worker No.:
District:
Date:
Case Name:
Interpreter Needed: _________
________
Language
Dialect
This office was notified of your initial Supplemental Security Income/State Supplementary Payment
(SSI/SSP) for the period_____________________________through__________________________. As
per your agreement, we billed the Social Security Administration (SSA) in the amount of $_____________to
repay the amount of Interim Assistance you received for that same period while SSA completed your
application for Supplemental Security Income payments. SSA will notify you about how the remaining SSI
money (if any) due you will be released by SSA.
SSI/SSP PAYMENT
If you disagree with the amount of SSI/SSP payment, contact your local Social Security Office. The
amount of the initial SSI/SSP payment is subject to the SSA appeal process. Request for
reconsideration must be filed within 60 days after the date the notice of the initial determination is
received by you.
INTERIM ASSISTANCE PAYMENT
If you disagree with the amount billed to the SSA, please contact the California Depar tment
of Social Services. This action is subject to the state hearing provision described on the reverse side
of this form.
COMMENTS:
The law and/or regulations governing this action are:
Department of Social Services/Eligibility Assistance Standards Manual Section (EAS) 46-337
42 U.S. Code, Section 1383(g)
20 CFR 416.1910
If you have any questions please contact me.
COUNTY/STATE REPRESENTATIVE
AGENCY
TELEPHONE
DATE:
SSP 18 (4/15)