Welfare Advocate Forms - Coalition of California Welfare Rights Organizations, Inc.

Hearings

pdf State Hearing Conditional Withdrawal Form – Fillable

In CCWRO Hearings Forms

” STATE OF CALIFORN IA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES WITHDRAWAL CONDITIONAL WITHDRAWALS OF REQUEST FOR HEARING I, , the undersigned do hereby: Withdraw my request for a state hearing before the State Department of Social Services. I understand that by withdrawing my request, I lose my right to a hearing on that request. I also understand that by withdrawing my request for hearing, aid which has been paid because of the request will stop without further notice. I may, however, file a new hearing request raising the identical issue provided that the new request is timely per Manual of Policies and Procedures Section 22-009. Conditionally withdraw my request for a state hearing before the State Department of Social Services. I understand that by conditionally withdrawing my request for hearing, aid which has been paid because of the hearing request will stop without further notice. I understand that the county will issue a redetermination notice within 30 days and that I must request a hearing within 90 DAYS of the county’s notice if I am not satisfied with the county’s reconsideration of my case. Upon such renewal, I shall have the same rights I would have had if I had not signed this conditional withdrawal. NOTE: A conditional withdrawal must provide that the actions of both parties will be completed within 30 days. The reasons for or conditions of this withdrawal are: Signed Signed (County Representative) (Claimant) (County Address) (City) (Telephone Number) (Zip Code) (Date) (Date) (Zip Code)(City) (Address) (Telephone Number) NOTE: A Conditional Withdrawal must also be signed by a County Representative or it is invalid. DPA 315 (7\/99) County Case No: Filing Date: Hearing Date: Hearing Time: Case Name: State Hearing No: County: box 1: Off case name: state hearing no: county: county case no: filing date: hearing date: hearing time: name 1: box 2: Off box 3: Off box 4: Off reason ln 1: reason ln 2: reason ln 3: reason ln 4: reason ln 5: reason ln 6: date signed 1: date signed 2: claimant address: county address: city\/state: city\/state 2: zip code: zip code 2: phone number 1: phone number 2: ”

pdf SHD Reopen postpone form

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pdf SAR 7 fillable Form

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pdf How to get a State Hearing Tape fillable(11 2020)

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pdf Authorized Representative form DPA19

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pdf 2023 CCWRO FH Subpoena & subpoena decus tecum

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pdf SSI – SSI Room rental statement SSA 795.pdf

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” Form SSA-795 (2-76) Form Approved OMB No. 0960-0045 SOCIAL SECURITY ADMINISTRATION STATEMENT OF CLAIMANT OR OTHER PERSON NAME OF NUMBER HOLDER SOCIAL SECURITY NUMBER NAME OF PERSON MAKING STATEMENT (If not NH) RELATIONSHIP (to NH) Understanding that this statement is for the use of the Social Security Administration, I hereby certify that… ______________________________ rents a room in my home and pays me $______ per month. This is strictly a BUSINESS RELATIONSHIP and we do not consider ourselves as members of the same household. We are related as a parent and child. He\/She does have access to adequate cooking facilities and food storages. If someone other than ______________________________________ rented a room in your house, how much would you charge per month? $___________. If less, why? Please explain below. _________________________________________________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________ Is _______________________________ obligated to pay rent as a condition to stay? yes no I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal Law and \/or State Law. I affirm that all information I have given in this document is true. SIGNATURE OF PERSON MAKING STATEMENT Signature (First name, middle initial, last name) (Write in ink) SIGN HERE Date (Month, day, year) Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route) Telephone Numbers (Include Area Code) Home ( ) Work ( ) – City and State ZIP Code Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses 1. Signature of Witness 2. Signature of Witness Address (Number & street, City, State & ZIP Code) Address (Number & street, City, State & ZIP Code) NAME OF NUMBER HOLDER: SOCIAL SECURITY NUMBER: NAME OF PERSON MAKING STATEMENT If not NH: RELATIONSHIP to NH: rents a room in my home and pays me: per month This is strictly a: rented a room in your house how much: If less why Please explain below: would you charge per month 1: would you charge per month 2: would you charge per month 3: obligated to pay rent as a condition to stay: Date Month day year: Mailing Address Number and street Apt No PO Box Rural Route: City and State: ZIP Code: 1 Signature of Witness: 2 Signature of Witness: Text1: Text323: Address Number street City State ZIP Code: Address Number street City State ZIP Codevqek: ”

pdf SSI – SSI expense form

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” Social Security Administration Form Approved OMB No. 0960-0045 STATEMENT OF CLAIMANT OR OTHER PERSON Name of Wage Earner, Self-employed Person, or SSI Claimant Social Security Number Name of Person Making Statement (If other than above wage earner, self-employed person, or SSI claimant) Relationship to Wage Earner, Self-Employed Person, or SSI Claimant Understanding that this statement is for the use of the Social Security Administration, I hereby certify that the following are my average monthly expenses for the period of Normal household expenses 1. Mortgage payments $ 2. Property Insurance (annual divided by 12) $ 3. Property Taxes (annual divided by 12) $ 4. Food $ 5. Electricity $ 6. Gas $ 7. Water $ 8. Garbage Removal $ 9. Telephone $ 10. Cable TV $ 11. Security System $ 12. Home Repairs $ Personal expenses for the family (average monthly costs) 1. Recreation, social functions, movies, restaurants $ 2. Club membership $ 3. Charity donations $ 4. Clothing $ 5. Haircuts, manicures $ 6. Dental bills (after insurance) $ 7. Medical bills (after insurance) $ Installment payments 1. Car insurance $ 2. Car loan payment $ 3. Car expense (gas) $ 4. Credit Card monthly payments $ 5. Lay-away accounts $ 6. Other retail accounts $ 7. Miscellaneous expenses $ Form SSA-795 (09-2015) ef (09-2015) Signature (First name, middle initial, last name) (Write in ink) Date (Month, day, year) Telephone Number (Include Area Code ) I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment. SIGNATURE OF PERSON MAKING STATEMENT Mailing Address (Number and street, Apt. No.,P.O.Box, Rural Route) Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses. 1. Signature of Witness 2. Signature of Witness Address (Number and street, City, State, and ZIP Code) Address (Number and street, City, State, and ZIP Code) Privacy Act Statement Collection and Use of Personal Information Section 205a of the Social Security Act (42 U.S.C. 405a), as amended, authorizes us to collect the information on this form. We will use this information to determine your potential eligibility for benefit payments. Furnishing us this information is voluntary. However, failing to provide us with all or part of the requested information may affect our ability to evaluate the decision on your claim. We rarely use the information you provide for any purpose other than for determining entitlement to benefit payments. However, we may use the information you give us for the administration and integrity of our programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include, but are not limited to, the following: 1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and\/or coverage; 2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and the Department of Veterans’ Affairs); 3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally-funded or administered benefit programs and for repayment or incorrect payments or delinquent debts under these programs. A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notices, 60-0089, Claims Folders Systems. This notice and additional information regarding our programs and systems are available online at www.socialsecurity.gov or at your local Social Security office. Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Form SSA-795 (09-2015) ef (09-2015) City and State ZIP Code Name of Wage Earner Selfemployed Person or SSI Claimant: Social Security Number: Name of Person Making Statement If other than above wage earner selfemployed person or SSI claimant: Relationship to Wage Earner SelfEmployed Person or SSI Claimant: the following are my average monthly expenses for the period of: undefined: undefined_2: undefined_3: undefined_4: undefined_5: undefined_6: undefined_7: undefined_8: undefined_9: undefined_10: undefined_11: undefined_12: undefined_13: undefined_14: undefined_15: undefined_16: undefined_17: undefined_18: undefined_19: undefined_20: undefined_21: undefined_22: undefined_23: undefined_24: undefined_25: undefined_26: 1 Signature of Witness: 2 Signature of Witness: Address Number and street City State and ZIP Code: Address Number and street City State and ZIP Code_2: Text1: Text2: Text3: Text4: Text5: ”

pdf SSI – SSA 795 Continued benefits filing for formal reconsideration

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” NAME OF PERSON MAKING STATEMENT (If other than above wage earner, self-employed person, or SSI claimant) SOCIAL SECURITY NUMBER Understanding that this statement is for the use of the Social Security Administration, I hereby certify that – Form SSA-795 (8-2002) ef (12-2005) Destroy Prior Editions SOCIAL SECURITY ADMINISTRATION STATEMENT OF CLAIMANT OR OTHER PERSON RELATIONSHIP TO WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT Form Approved OMB No. 0960-0045 NAME OF WAGE EARNER, SELF-EMPLOYED PERSON, OR SSI CLAIMANT kevinaslanian Highlight 2. Signture of Witness Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the individual must sign below, giving their full addresses. I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. SIGNATURE OF PERSON MAKING STATEMENT Telephone Number (Include Area Code) – ( ) – Signature (First name, middle initial, last name) (Write in ink) SIGN HERE Date (Month, day, year) Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route) ZIP Code 1. Signture of Witness Address (Number and street, City, State, and ZIP Code) City and State Address (Number and street, City, State, and ZIP Code) Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form. Text2: Text4: Text5: I have been advised of my right to have my SSI Text7: continued to me pending the outcome of the appeal regarding the decision Text8: of SSA to reduce or stop my benefits. Text9: I understand that, if I lose my appeal, I will be asked to pay this money back, Text10: including all checks received after this action takes effect, through the months Text11: such benefits were received if the appeal is not decided in my favor. Text12: I have the right to ask that I not have to pay the money back. If I do ask, Text13: and if it is determined by SSA that my appeal was made in good faith and that Text14: I need my income and resources for ordinary and necessary living expenses Text15: or that other factors apply, I will not have to pay the money back. I also understand Text16: that SSA will provide me with more information about waiver recovery of Text17: an overpayment, if I would like it. Text18: I will not be asked to pay back any Medicaid benefits I received while I was appealing. Text19: If I win my appeal, any money I am owed will be paid. Text20: During this benefit continuation period and while my appeal is pending, I agree Text21: to promptly report to SSA any changes which may affect my right to receive Text22: benefits, working, changes in my income and resources, and living arrangements. Text23: I understand hat I turn down continued benefits during the specified 10-day Text24: period , I will not have the chance (if he 10-days have passed) to elect continued Text25: benefits again. Text26: I WANT CONTINED BENEFITS PENDING THIS RECONSIDERATION. Text27: Text28: STATEMENT OF CLAIMANT Text29: Text30: I acknowledge that I understand my responsibilities and that I have been Text31: given a copy of this signed statement regarding my choice of continuation Text32: options: Text33: Text34: Election: Text35: __ Yes. I want all benefits continued. If I do not get my benefits I will Text36: not be able to pay for food and shelter. Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Check Box1: Yes Text1: Text3: Text6: ”