Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
- To provide a form to refer clients to the Social Security Administration (SSA) who may be eligible for Supplemental Security Income (SSI) benefits.
- To provide a form used by SSA to inform the state agency of action on SSI referrals.
- To provide a form the state agency staff use to notify SSA of the month the person certified for SSI will receive his last benefit.
- To provide a form the state agency uses to notify SSA when the family of an SSI recipient is certified for TANF so SSA can recompute SSI benefits.
When to Prepare
The worker completes Part I of Form H1016 to refer to SSA a client who is potentially eligible for SSI benefits. The SSA staff respond by completing Part II. The worker completes Part III to inform SSA of the TANF grant status of SSI recipients.
Note: For certified TANF clients, do not send Form H1016 to SSA until the case and client number are assigned.
Number of Copies
The worker completes an original and one copy.
The worker sends the original to SSA and files the copy in the client's case record.
SSA staff return the original when a decision is made about SSI eligibility.
If the person referred to SSA receives TANF and is awarded SSI benefits, the worker completes all copies of Part III to notify SSA of the month of the client's last TANF benefit. The worker sends the copy to SSA and files the original in the client's case record.
State agency staff keep the case record copy of Form H1016 for three years after closure/denial of TANF or MAO eligibility.
PART I — Referral to Social Security Administration
To — Enter the address of the Social Security district office.
From — Enter the address of the state agency office where the form originates.
TANF/Foster Child/MAO — Enter an "X" in the box to indicate the type of assistance the client receives.
Name of Client — Enter the name of the client being referred (last name first) as shown on the client's Social Security card.
Date of Birth — Enter the month, day and year of the client's birth.
Soc. Sec. Account Number — Enter the client's Social Security account number. Enter "NONE" if the client has never had an account number. Enter "NOT KNOWN" if an account number has been assigned but the client does not know the number.
Soc. Sec. Claim Number — If an account number is not available but the client has a claim number, enter the claim number.
Case Name — Enter the case name as shown in state agency records.
Case No. — Enter the client's case number.
Mailing Address — Enter the client's complete mailing address.
Residence — Enter the client's complete residence address if different from the mailing address.
Telephone No. — Enter the client's telephone number. Enter "NONE" if the client cannot be reached by telephone.
Is medical evidence available... — Check as appropriate. The state agency may not release medical information unless requested in writing by SSA.
Person to be paid... — Enter the name, address and telephone number of the person to be paid in the client's behalf. Complete this section only if the client is unable to receive his check or is less than 18 years old.
For Certified TANF Recipient Only — If the client being referred to SSA is currently certified for TANF, enter the amount of the TANF grant, including this person; subtract the amount the TANF grant would be if he were excluded; and enter the difference. This difference is counted by SSA as income only for any month when overlapping payments are received. This is not applicable to foster care.
Signature — The state agency worker signs and dates the form.
PART II — Health and Human Services Commission Enterprise
SSA staff complete this part of Form H1016.
If the client is awarded SSI benefits, SSA staff check the box "Awarded SSI." SSA staff enter the date when the first SSI check will be mailed and the amount of the monthly benefits the client will receive.
If the client was denied SSI benefits, SSA staff check the box marked "Denied."
The district or branch manager or designee signs and dates the form and returns it to the state agency.
PART III — Health and Human Services Commission Enterprise
The state agency person completes this part of Form H1016 by checking and completing the appropriate box on both copies of the form.
Active Client — Enter the case name, case number, client number (as reported on the Form H3087), month the benefits began and the amount of the client's benefits. (For MAO only, enter "MAO ONLY.")
Grant Notification — Complete this part only to notify SSA of the certification for TANF of the family of an SSI recipient. Enter the Social Security number (if known), name and client number of the SSI recipient. Enter the case name, case number and month the benefits begin.
Denied — Enter the last month the client will receive benefits.
Not Eligible — Self-explanatory.
Signature — The state agency person signs and dates the form, files the original and sends the copy to SSA.