.02 FA‑020 Instructions‑
Complete the following information on the FA‑020 before giving it to the participant. The first section of the form contains the following:
CASE NO: The number of the case.
DATE SENT: The date the FA‑020 is sent to SSA.
CASE NAME: The name of the PI of the case.
CONTROL NUMBER/CLIENT ID: The proper sequence for this number is the two-digit BENDEX Code (Arizona is AZ) followed by the ten-digit Participant ID number. Place slashes through all zeros.
SSA uses this number to system match and electronically update the participant's Social Security Number (SSN) in AZTECS.
ELIGIBILITY INTERVIEWER'S NAME: The name of the EI who filled out the FA‑020.
ELIGIBILITY INTERVIEWER'S PHONE NUMBER: The phone number of the EI who filled out the FA‑020.
The next section has four separate blocks for different information. The information in each block is about the participant being referred to SSA.
Block number one contains the following items:
NAME (Last, First, M.I.): The participant's last name, first name, and the middle initial.
BIRTHDATE: The participant's date of birth (MMDDYY).
SSN: The participant's SSN when known.
SEX: Check the correct box for male or female.
Block number two contains CLIENT STATUS. Check the box that applies to the participant.
Block number three contains FILED FOR/RECEIVING ASSISTANCE. Check the box that indicates the program the participant has requested or is receiving. At least one box must be checked.
Block number four contains THE ABOVE-NAMED PERSON IS BEING REFERRED FOR. Check all boxes that apply. At least one box must be checked.
NOTE When the OTHER REFERRAL REASON box contains an X, write an explanation of why the participant is being referred.
Block number five contains STATE DATE PROVIDED TO SSN VERIFICATION SYSTEM IS SHOWN ABOVE. When the information in item I on the FA‑020 matches the NUMIDENT records, check the YES box. When the referral is to clear up a problem with this information, check the NO box and explain the problem.
The next two sections are filled out, signed, and dated
by SSA.
The final section of the FA‑020 contains PLEASE MAIL REPLY TO. In the address space located in the lower left hand corner of the FA‑020, write the local office address.