Form Ssp 17 - Notice Of Action And Right To Request A State Hearing On Interim Assistance
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2STATE 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 received on _____________________________________________ a Supplemental Security Income/State
Supplementary Program (SSI/SSP) payment for you in the amount of $ _____________________________________ ,
for the period ________________________________ through ___________________________________. As per your
agreement, we are sending you the balance of $_______________ after deducting the amount of $_______________ ,
to repay the amount of assistance you received from Interim Assistance for that same period while Social Security
Administration (SSA) completed the work on your eligibility determination for SSI/SSP benefits.
SSI/SSP PAYMENT
If you disagree with the amount of the SSI/SSP payment of $______________________________, contact your local
Social Security Office. The amount of the total SSI/SSP payment is subject to the SSA appeal process. A request
for reconsideration must be filed within 60 days after the date the notice of the initial determination is received.
INTERIM ASSISTANCE PAYMENT
If you disagree with the amount of Interim Assistance withheld from your SSI/SSP payment or you contend that we did
not send you the balance, if any, as shown above within the 10 working days, please contact the State Department of
Social Services. This action is subject to the state fair 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 and Assistance Standards Manual Section 46-337
If you have any questions please contact me.
County/State Representative
Agency
Telephone
Date:
SSP 17 (4/99)
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