Appendix A: Notice to Individual

The Social Security Administration has informed the Department of Human Services that effective ______________, your first regular Supplemental Security Income (SSI) benefit will be issued. 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 payment.

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

Thank you.

___________________________

Worker's Signature

___________________________

CAO/District

___________________________

Address