SSP Central Unit Fax Number: 717-346-0363
Today’s Date: ____________
We are referring the following individual for an SSP-Only eligibility determination.
|
Name |
Social Security Number |
CO/Case Record |
Phone Number |
Application Date Stamp: ____________
[ ] Client receiving SSD or Elderly or MRT Certified
[ ] MRT Requested Date sent______________
|
Gross Monthly Income |
Resources |
||
|
Type/Source |
Amount |
Type/Source |
Gross Amount |
COMMENTS:
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_________________________________________________________________________________________________
CAO SSP Liaison Phone Number
Reissued July 19, 2008, replacing March 31, 2006; reviewed March 16, 2012