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Authorization for Reimbursement of Interim Assistance - Initial Payment

 

Name_________________ Social Security Number_______________

Address__________________________________________________
City/Town/Zip Code

The term County means the [Name of County Agency].

What am I authorizing the County to do by signing this authorization?

If I am found eligible to receive Supplemental Security Income (SSI) benefits, I understand that I am authorizing the Commissioner of the Social Security Administration (SSA) to send to the County:

  • My first retroactive payment of SSI benefits, or
  • An amount equal to the amount of reimbursable public assistance the County gave to me, if law restricts the manner in which my SSI money can be released to me.

How will the County be paid for the reimbursable public assistance it gave to me?

If I am found eligible to receive SSI money, SSA will send my first retroactive SSI payment to the County or an amount equal to the amount of reimbursable public assistance the County gave to me when law restricts the manner in which my SSI money can be released to me. The County may:

  • Deduct from my first retroactive SSI payment the sum of all County public assistance benefits made to, or on behalf of, me by the County in situations when law does not restrict the manner in which my SSI money can be released tome, or
  • Have SSA to send it an amount equal to the amount of reimbursable public assistance the County gave to me when law restricts the manner in which my SSI money can be released to me,

for months beginning with:

  • The first month for which I am eligible to receive an SSI payment and ending with the month my SSI payment begins, or
  • The following month if the County cannot promptly stop making its last public assistance payment to me.

The County cannot be reimbursed for assistance it gave to me if that assistance was financed wholly or partly from Federal dollars.

Does this authorization serve as a protective filing for SSI benefits?

Yes, signing this form serves as a signed statement of my intention to claim SSI benefits if I have not filed an SSI application as of the date this authorization is received by the County. My eligibility for SSI benefits may begin as early as the date I sign this form if I file an application at a social security office for SSI benefits within 60 days after that date. This form also serves as a notice from SSA that I have sixty days from the date the County receives this form to file for SSI benefits. However, if I do not file an application for SSI benefits at a Social Security Office within 60 days after that date, then I understand that I cancel my intention to claim SSI benefits and this authorization no longer protects my filing date for SSI.

How long is this authorization binding on the County and me?

This authorization is binding on the County and me for one calendar year beginning with the date the County received it. If the County does not notify SSA with in thirty (30) calendar days of the date that I signed this authorization, the authorization is not binding on the County or me. Also, this form must be signed and dated by both a County representative and me to be a valid agreement that authorizes the County to receive interim assistance reimbursement from my SSI payments. However, if I have already applied for SSI before the County received this authorization, or I apply for SSI within one calendar year of the date described above, or I file a timely request for an administrative or judicial review within the time permitted under SSA's regulations, this authorization will remain in effect, even if beyond the one calendar year period, until such time as:

  • SSA makes the initial SSI payment on my initial claim; or
  • SSA makes a final determination on my claim; or
  • The County and I both agree to terminate this authorization.

What rights and appeals are available to me under this authorization?

The County is required to:

  1. Pay to me any balance due from the retroactive SSI payment with in 10 working days of the receipt of my SSI payment.

  2. Give me written notice explaining:

  • How much SSA repaid the County for interim assistance it gave to me;
  • The balance, if any, due me unless the Social Security Act requires SSA to pay me such balance. [In such an event, SSA will notify me of the manner in which the balance will be paid to me.]; and
  • That I will have an opportunity for a hearing with the County if I disagree with it's actions regarding repayment of interim assistance or any action it took regarding this authorization.

_____________________________ Date _______________________
Signature of Member

____________________________ Date ________ GR Code________
Signature of County Representative

Last revised June 13, 2019