Appendix A: Notice to Client

The Social Security Administration has informed the Department of Public Welfare that effective ______________, your first regular Supplemental Security Income (SSI) check will be received. Notification of your eligibility for SSI has not been forwarded to you by the Social Security Administration, but will be provided to you prior to the effective date of your first regular SSI check.

If you do not receive your first regular SSI check by the above effective date, contact your local Social Security District Office to receive verification that your SSI check has been delayed and provide this verification to the County Assistance Office.

Thank you.

___________________________

Worker's Signature

___________________________

CAO/District

___________________________

Address