Department of Health Care Services

State of California—Health and Human Services Agency

SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE
Instructions:
• To CWD:

Please complete Part I. Retain original for your records, copy for recipient/SSA. Client must take this form to SSA.

•	 To Recipients:

Read the back of this form. Take the necessary documentation to the Social Security Administration Office listed below in
Part I.B.

•	 To SSA:

This form is a request for the action noted in Part I.C. Please complete Part II of this form and distribute as noted in
Part I.A. If you have any questions, the eligibility worker's name and phone number are provided.

PART I: TO BE COMPLETED BY THE COUNTY WELFARE DEPARTMENT 

A.

Please enter the complete county welfare office name and address within the brackets provided.

SSA, after completion:
Mail this form to the county welfare office.
Return this form to the recipient to be
returned to CWD.
B.

C. The bearer of this form is an applicant for, or recipient of, Food
Stamps, Cash Aid, or Medi-Cal. The following service is required:

Social Security Office Information

Name of SSA District/Regional Office

Los Angeles

✔

Original SSN card

Address (number and street)

Duplicate SSN card
City

State

ZIP code

Info on SSA's Numident File needs to be verified.
Name
DOB
Sex

D. Applicant/Recipient Information
Recipient's name (last, first, middle initial)

Info on SSA's Numident File needs to be corrected.
Name
DOB
Sex

Joe Jackson
Date of birth (month/day/year)

064 70 6733
SSN: ______________________

Sex (M or F)

02/02/80

M

Note: Recipient must provide verification of change.

County ID per MEDS

Recipient has been assigned two SSNs. Please take action
to delete all but one.

X
Recipient's SSN (if applicable)

064 70 6733

Two recipients appear to have been assigned the same SSN.
Please verify correct number for recipient from Numident File.

Case name

E.

CWO Information

Name of Eligibility Worker
Date form completed

F.
E.W. Worker

Comments

E.W. phone number

PART II. TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION DISTRICT/REGIONAL OFFICE 

A. Date received

B.

C. Comments

D. SSA Representative—print name

MC 194 (05/07)

Signature

Result of Referral
1.

Recipient has completed an SSN application (including
Form SS-5 and other proof) and application is being
processed.

2.

Insufficient ID.

3.

SSN application is not being processed. (Explain.)

4.

Other. (Explain.)

Telephone number

SSA REFERRAL INFORMATION SHEET 

(For Medi-Cal, Food Stamp, and CalWORKs Recipients) 

YOU MUST CONTACT SOCIAL SECURITY
Public Law requires that each person who applies for or receives full-scope Medi-Cal, Food Stamps, or
California Work Opportunity and Responsibility to Kids must have or apply for a social security number.
For the applicant/ recipient noted on the reverse side, either (1) the Social Security Administration does
not have a social security number on file, or (2) the information provided by the Social Security
Administration and the information provided to the eligibility worker do not agree. To correct this situation,
you must contact the Social Security Office indicated on the reverse side of this referral form. DO NOT
MAIL THESE FORMS TO THEM.
NOTE:	 Age, citizenship or alien status, and identity must all be documented. One of the identification
documents must be a birth or baptismal certificate established BEFORE age 5. If one is not
obtainable, refer to Column A for acceptable substitutes. In addition, if the applicant/recipient is
a U.S. citizen born outside of the U.S. or an alien, one of the items listed in Column B must be
presented.
Column A
1. Evidence of Age/Citizenship
•
•
•
•
•
•
•
•	

School records
Church records
Census records (state or federal)
Insurance policy
Marriage records
Draft card
U.S. passport
Other records indicating applicant's age or
date and place of birth

2. Evidence of Identity
•
•
•
•
•
•	

Driver's license
State identification card
Voter's registration
School records
Health records (doctor's, hospital's, etc.)
Any other document which shows
applicant's signature, photograph, or
description

Column B
1. 	 If you are now a U.S. citizen born outside the
U.S., take one of the following items in
addition to the item(s) required in Column A:
•
•
•
•
•
•
•

U.S. citizen identity card
U.S. passport
Naturalization certificate
Certificate of citizenship
Consular report of birth
Form I-179 (U.S. citizen card)
Form I-197 (U.S. citizen resident card)

2. 	 If you are an alien, take one of the following
items in addition to the item(s) listed in
Column A:
•	 Form I-151 or I-551 (Alien Registration
Receipt Card)
•	 Form AR3a, I-94, I-95a, I-84, I-85, I-86, or
SW-434
•	 Letters from Immigration and
Naturalization Service showing alien
status

If you have a question concerning the two identification documents which you must take to the Social
Security Office, please contact the Social Security Office.

MC 194 (05/07)

