Appendix B: Personal Care Supplement Client Notice

Individual Has Met the Requirements for the Domiciliary Care/Personal Care Supplement

We have certified that effective [month/year] you have met the requirements for the Domiciliary Care/Personal Care Supplement to the Federal Supplemental Security Income (SSI) Program. On [date] we sent the Social Security Administration (SSA) an authorization to use the Domiciliary Care/Personal Care Supplement to determine your SSI payment level. The SSA will determine your eligibility for SSI or your new benefit amount if you are now receiving SSI. The SSA will let you know of its decision, the effective date, and the payment amount.

If you wish to appeal our decision regarding this certification, please follow the instructions found in the Appeal and Fair Hearing section of this notice. Domiciliary Care/Personal Care Supplement

Individual Has Not Met the Requirements for the Domiciliary Care/Personal Care Supplement  

We have determined that you have not met the requirements for the Domiciliary Care/Personal Care Supplement to the Federal Supplemental Security Income (SSI) Program because ______ . If you wish to appeal our decision please follow the instructions   found in the Appeal and Fair Hearing section of this notice. Domiciliary Care/Personal Care Supplement