Authorization for reimbursement of interim assistance form. Jul 1, 2025 · Clients who have applied for SSI, are appealing a SSI decision, or whose SSI benefits are suspended must authorize DHS to receive reimbursement of GA benefits by completing the SSI Interim Assistance Authorization (DHS-1795). When you sign this form, you are saying that you have the intention of filing for SSI benefits if you have not already applied for benefits. For the purpose of this Authorization Form: The term “State” means the California county interim assistance (IA) agency (s) that the California Department of Social Services has an interim assistance reimbursement agreement with and that paid you public assistance. Authorization for Reimbursement of Interim Assistance Form To utilize the full functionality of a fillable PDF file, you must download the form, and fill in the form fields using your default browser. To finish setting up your account, please call DTA at 1-877-382-2363. For the state to receive reimbursement, we must receive the signed authorization form before we send the first recurring monthly SSI payment to the recipient, if any payment is due. Yes, if I have not already filed a SSI application, SSA must accept this form and use the date I signed this authorization as the date I applied for SSI if I file an SSI application within 60 days of the date I signed the authorization. . Oct 21, 2011 · SSA can use this form to protect your filing date. Jul 10, 2025 · If you are trying to create a new DTA Connect account, you must speak to a staff member. ltgpj nbjtq kmhr mcoora cmyth pzazfpem wbrti rfnpr auwou qwjc