SSA-8010-BK - Intranet Submissions (SSI Claims System)

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SCREENSHOTS
FACSIMILE 1: NON-CASH PUBLIC ASSISTANCE
Non-cash public assistance
NAME

SOCIAL SECURITY NUMBER(SSN) ROLE

SSSSSSSSSSSSSSSSSSSS SSSSSSSSSSSSSSS SSSSSSSSSSSSSSSSSSSS SSSS SSS-SSSSSS
SSSSSSSSSSSSSSSSSSSSSSSSS
* Indicates required Information
[1-m]
*TYPE
Supplemental nutrition assistance program (snap)
Select from favorites or type source information
[2-o]
[˅/˄] SHOW/HIDE FAVORITES
Non-Cash PUBLIC ASSISATNCE FAVORITES
[3-C]

[4-O]

[Refresh]

Manage Office Level Favorites

[5-d]

[6-d]

Source

Address

SS[Varies]ss
[9-m]

ss[varies]ss

[7-d]

[8-o]

phone

actions

ss[varies]

[select]

[10-o]

*Source xx[maximum of 40 characters]xx

[ ] unknown

Id XXXXXXXXXXXX

address
[11-m]

[12-o]

[13-o]

*Street 1

Street 2

Street 3

xx[Max of 22 Char]xx
22 Char]xx
[15-O]

[14-o]
Street 4

xx[Max of 22 Char]xx

[16-O]

CITY/TOWN

xx[Max of 22 Char]xx

[17-O]

State/Territory

XX[Max of 22 CHAR]XX

Zip Code

–-

99999

[18-O]
Unknown
[19-O]
Contact
xx[Maximum of 40 Characters]xx
Phone
[20-O]
(999)999-9999
10 Digit Number
Monthly Eligibility
[21-M]

[22-M]

*Date From
(MM/YYYY)
99/9999

[23-O]

*Date To

[24-o]

Verified

[25-O]

Unknown

(MM/YYYY)

99/9999

[]

[]

[Delete]

Actions

xx[max of

[26-o]
[˅/˄] SHOW/HIDE PERSON REMARKS
[27-O]
PERSON REMARKS (PRINTED): XX[MAXIMUM OF 1000 CHARACTERS]XX
[28-o]
[˅/˄} SHOW/HIDE FILE DOCUMENTATION NOTES
[29-O]
FILE DOCUMENTATION NOTES: XX[MAXIMUM OF 1000 CHARACTERS]XX
[30-O]
[Add Another]

[Clear Page/Undo Changes]

[Delete]

D.
SCREEN SHOT 1: NON-CASH PUBLIC ASSISTANCE
1.
DEFAULT SCREEN