PURPOSE: To request information regarding public assistance benefits received from another state.
Use this form at application or reinvestigation or when information is received indicating that an individual works or receives public assistance benefits from another state. This inquiry will be appropriate if the claimant or an assistance group/household member:
FORM AVAILABILITY: The IM-39A is available as an electronic form only.
NUMBER OF COPIES AND DISPOSITION: Complete an original and one copy. Place the copy in the case record. The copy may be destroyed when the completed original is received.
MANUAL REFERENCES:
BCCT/MA: 1300.000.00 - 1325.000.00
OAA/PTD: 1000.000.00 - 1060.010.00
MAF/MC+: 0905.000.00 - 0955.020.00
MA: 0800.000.00 - 0870.045.00
SNC: 0600.000.00 - 0635.005.00
SAB/BP: 0400.000.00 - 0440.000.00
TA: 0200.000.00 - 0300.015.00
INSTRUCTIONS FOR COMPLETION:
FROM
COUNTY OFFICE NAME: Enter the name of the requesting county office.
TELEPHONE NO: Enter the office telephone number, including the area code.
DATE: The date is system generated when the letter is created.
ADDRESS (STREET): Enter the county office street address.
CITY, STATE, ZIP CODE: Enter the city, state, and zip code of the county office address.
TO
STATE AGENCY NAME: Enter the name of the public assistance agency where the request is being sent.
NOTE: Agency names and addresses may be obtained from the Public Human Services Directory available in each county office, or through the receiving state’s web site.
RE
CASE NAME: Enter the name of the claimant.
SOCIAL SECURITY NUMBER: Enter the claimant’s Social Security Number.
CASE DCN: Enter the claimant’s Departmental Client Number (DCN).
NAME (IF DIFFERENT FROM CASE NAME): Enter the name of the individual for whom the information is requested if it is not the claimant listed in Case Name.
SOCIAL SECURITY NUMBER: Enter the Social Security number of the individual for whom the information is requested if it is not the claimant listed in Case Name.
THE ABOVE-NAMED INDIVIDUAL--: Check the appropriate box in this section that fits the case situation. If “Other” is selected, thoroughly explain the type of assistance received from the other agency.
TYPE OF ASSISTANCE/CASE STATUS: The receiving agency completes this section.
COMMENTS: Enter any special requests that need further clarification, or any additional information that may be useful.
Example: “Ms. A states she received Medicaid in Illinois until last May. She states her case was closed when she moved to Missouri.”
HOUSEHOLD MEMBER SIGNATURE/DATE: The individual for whom information is needed signs and dates the form.
ELIGIBILITY SPECIALIST: Enter the name of the Eligibility Specialist who is requesting the information.
TELEPHONE NUMBER: Enter the office telephone number of the Eligibility Specialist who is requesting the information.
CASELOAD NO: Enter the caseload number of the Eligibility Specialist who is requesting the information.