Attachment 1

(DRAFT)
LOCAL DISTRICT LETTERHEAD

	Date:
	Case Number:
	Case Name:
(Address of Local Social Security Office)
_____________________________

_____________________________

_____________________________	

Dear Social Security Administration:

Pursuant to Federal law, a Social Security Number is an eligibility requirement for the receipt of Federal
 
public benefits.  (42 U.S.C. 1320b-7(a)(1), (b)(1), (b)(2), (b)(4))

______________________________________________________________________ has been deemed
(Alien/Immigrant's Name)                        (Date of Birth)                        (Sex (M/F)) 

otherwise eligible for benefits under one or all of the following Federal Assistance Programs:

•	Temporary Assistance for Needy Families (42 U.S.C. 601 et seq.)
•	Food Stamps (7 U.S.C. 2011 et seq.)
•	Medicaid (42 U.S.C. 1396 et seq.)

Please assign a Social Security Number to _________________________ as the applicant has met all the
						(Alien/Immigrant's Name)

eligibility requirements for ________________________________________________________________,
      	(List the Federal Assistance Program(s) above in which Applicant Qualifies)

except for the possession of a Social Security Number.

If you have any questions regarding this request, you may contact _________________________________

at ____________________________________________________________________________________.	
Sincerely,

___________________________________
(Name)

___________________________________
(Title)