Appendix E: SSP Central Unit Referral to CAO

Date:

RE: Recipient Name: SSN: Recipient Number:

Please take action in eCIS, per the details below:

CAO Action Type: Current Category And Program Status Code:

Set New Reapp Date To: (Note: Clerical stand alone action is required to set the new reapp date)

The below fields will be completed only if there is a change that requires a revised entry in eCIS

IMCW Actions:

Effective Date of Benefit Change or Closure: New Monthly SSP Benefit Amount:

New Category/Program Status Code: New Citizenship Code: New Marital Status Code:

Clerical Actions: (should be completed if the new Payment Name is a Rep Payee)

New Payment Name: New Rep Payee Payment Name Code:

New Address 1: New Address 2:

New City: New State: New Zip: New Zip Ext: New Phone:

New Language Preference Code:

Central Unit Worker Comments:

Information needed for the completion of the 162 Notice

162 Notice Reason Code: 162 Notice Option Code:

Total countable monthly earned, unearned and deemed income: Countable Monthly Earned Income:

Countable Monthly Unearned Income: Countable Monthly Deemed Income:

Deemed Income is from: Federal Benefit Rate (FBR):

Reason this FBR Applies:

Combined FBR And SSP:

Countable Resources:

Description:

Countable Resources:

Description:

Reason for Non-Financial Eligibility:

Language Text Describing the Verification That Was Not Provided: