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City* State* AKALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWY Zip Code* Ward 12345678
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Date of Birth* (mm/dd/yyyy) Who is on the other side of your case?* (Ex: a government agency such as Social Security or the D.C. Department of Human Services. If you are unsure, please write "Not Sure.") Who lives with you? Please list each household member’s name and date of birth.* (If you live alone, you can write “No one.”)
Please provide the following information about your household income, which will be used to determine if you are eligible for our services. Please include all income that any member of your household receives. If you do not know exact figures, please provide your best estimate. For example, if your paycheck changes based on the hours you work each week, try to estimate your average weekly or monthly income. If we are not able to help you further based on your household income, the information in this section will not be entered into our system.
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Please provide the additional information below describing your legal matter. If you have multiple issues, please check all boxes that apply. If you need to return to an earlier part of the form, please use the “Back” button below instead of your browser’s “Back” button. Type of Public Benefits issue: Disability/Social Security/SSITANF (Temporary Aid for Needy Families)Food StampsMedicaid/Medicare/QMB/AllianceHome Health AideUnemployment Insurance
i. When did you file? ii. How did you file? (by visiting office, mail, etc.) iii. Do you have a copy of the appeal paperwork?
i. Once you have determined what stage of the process you are in--please refer to this chart again if you have any questions--you can submit either a Request for Reconsideration or a request for a hearing in front of an Administrative Law Judge. Please file an appeal ASAP and do not wait to talk to an attorney before filing-- what's most important is that you turn it in on time. ii. Are you still within that 65-day time period? YesNo
I. What are ALL of your medical conditions that keep you from working?
a. What are the symptoms of these conditions? b. How long have you had them? c. How do these symptoms limit your ability to work? For example, would you have trouble getting along with coworkers, or concentrating, sitting, or standing for long periods of time)? d. How frequently do the symptoms occur? How severe are they?
II. Where do you go for health care? List all of your doctors (and the type– primary care, cardiologist, etc.) III. Do you have current or past issues with substance abuse? (We ask this because it is something that the Social Security Administration will ask about.) YesNo
i. What substances? ii. CurrentPast
a. How long have you been using for?
b. Have you ever been in rehab? YesNo
a. How long were you using for? b. How long have you been clean? c. Have you ever been in rehab? YesNo
IV. What is the highest grade of school you completed? V. Were you ever in special education classes? If so, for what? VI. Are you currently working? YesNo
i. How much do you earn per month?
i. When was the last time you worked? ii. What kind of job was it? iii. What did you do in the job? (Ex: lifted boxes, drove vehicles, etc.) iv. Why did the job end?
VII. Please list all jobs you have held in the past 15 years, including the following details for each job:
VIII. Is there anything else we should know about your case?
1. What is the source of the other income? 2. Did you get the income Social Security thinks you did? YesNo 3. Did you report income to Social Security? If so, how? 4. Did you report income when it was received, or did you report it later? If later, how much later – after Social Security told you you were overpaid?
F. Is Social Security taking money out of your check to pay down the overpayment? YesNo
When did the withholding start? How much are they taking every month?
G. Do you have Medicare? YesNo
H. Have you filed an appeal of the overpayment? YesNo
What kind of appeal (Request for Reconsideration, Request to Waive Overpayment, or both)? Did Social Security stop any withholding of your benefits? YesNo
I. Is there anything else we should know about your case?
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a. When did/will your benefits stop? b. Did you get any notice about your benefits stopping? If so, what did it say? c. How much TANF were you receiving before your benefits stopped?
When were your benefits reduced? a. Did you get a letter from the Department of Human Services (DHS) about your benefits being reduced? If so, what did it say?
b. How much were you receiving before your benefits were reduced?
When did you apply? a. Did the Department of Human Services (DHS) say why you were denied? b. Do you disagree with their decision?
When did you apply?
3. Did you submit all the paperwork you were supposed to submit? Even if you didn't, please note that we can still consider your case. YesNoI don't know
a. When and where did you submit it? b. To the best of your memory, please list the documents you submitted.
Why not?
4. Did you appeal? YesNo
When? Do you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?
5. We need the following information to figure out how much TANF you should be getting:
a. How long have you been receiving TANF? OR How long were you receiving TANF for before it got cut off? b. Does your family have any other income?
i. Child support?
ii. SSI? Please include the name(s) of the person(s) receiving SSI, including children. iii. Income from working?
c. Do you have any barriers that would keep you from work activities or job searches for 20-30 hours per week?
i. Recent domestic violence? ii. Your own disability? iii. Your child’s disability?
Is there anything else we should know about your case?
2. What problem are you having with Food Stamps? Food Stamps stoppedFood Stamps were reducedFood Stamps application deniedApplied for Food Stamps, but haven’t heard anything
a. When and where did you submit it? b. To the best of your memory, please list the documents you submitted. For example, proof of income, proof of rent, proof of residency, children's birth certificate, proof of bank account, or other resources.
When? Does you have a hearing or pre-hearing conference scheduled? If so, which one and when is it?
We need the following information to figure out how much in Food Stamps you should be getting:
a. How many people in your household buy and/or prepare meals together? Please include adults and children. b. Please list the income for everyone in your household who buy and/or prepare meals together. This includes earned income (wages) and unearned income (like Social Security, TANF, and child support). c. How much do you pay in rent or mortgage every month? d. Do you pay any utility bills? YesNo
1. Which utilities are you paying? 2. Are the utilities you pay responsible for heating or coooling your home or apartment? YesNo
e. If applicable, how much do you pay in child support every month? f. Do you have any medical expenses that are not covered by insurance? If so, how much? g. If applicable, how much do you pay in childcare expenses every month? h. Please list the immigration status of you and everyone in your household, including each child. (Note: immigrant parents may apply for food stamps for their U.S. citizen or qualified immigrant children, even though the parents may not be eligible for food stamps.)
1. What type of health insurance do and/or did you have? Note: If you are not sure, please look at your card for the following:
2. When did your health insurance get cut off? 3. Do you know why your health insurance got cut off? 4. Did you receive a letter telling you your health insurance would get cut off? YesNo 5. If you received Medicaid, QMB or Alliance, when is the last time you recertified for this benefit? 6. Have you appealed the decision? YesNo
Please note: You have 90 days (from the date your insurance was cut off) to appeal the decision.
2. Does your problem involve getting Medicare to cover a prescription drug that you need? YesNo
In Section D of this form, you will find instructions on how to send us a copy of your Medicare card (red, white and blue card) and your prescription drug list. Your prescription drug list should include the name of the drug you are having problems with, if you can take the generic version of the drug, dosage, and how many you need to take every day.
3. Are you having trouble getting a medical procedure or object besides prescription medication, such as a medical device? YesNo
b. How does your inability to get this procedure or thing affect you? And how often does it affect you (on a daily, weekly, monthly basis, etc.)? c. Does your doctor or dentist believe that this procedure or thing is medically necessary? d. Have you appealed the denial of coverage? YesNo
i. Do you have a hearing date?
Please note: You have 90 days (from the date of the denial notice) to appeal the decision.
A. Did you have Medicaid/Medicare/QMB/Alliance at the time of the service? If yes, which one(s)? B. Did you tell your provider about your insurance at the time of the service? YesNo
I. Were you denied services or are you appealing a decision to reduce/terminate the number of home health aide hours you receive? Applied but denied servicesReceived notice/otherwise informed that my hours would be reducedReceived notice/otherwise informed that my hours would be terminatedHave filed an appealHave requested aid pending appealHave a hearing date (and if so, what is it?)
1. How many hours per day AND how many days per week of home health services were you getting before the reduction or termination? 2. How many hours per day AND how many days per week will you now receive (if any), per the agency’s recent decision? 3. What is the name of the home health agency providing the care? 4. What is the name of the home health agency providing case management?
II. Why were you denied or why were the home health aide hours reduced/terminated? Over-incomeOther reason:
Do you have any outstanding medical expenses that insurance has not paid for? YesNo
Please list the dates and amounts of all of your outstanding medical bills.
III. Did you get a written notice of the decision? If not, how did you find out about the decision?
IV. What are your medical conditions? V. How do they affect your ability to do things around the home? VI. Please describe in as much detail as possible how the aide helps you (or a potential aide would help you) with the following, if you need the help:
a. Bathing: b. Dressing: c. Toileting: d. Walking/Ambulating: e. Managing your medicines: f. Preparing your meals: g. Eating your meals: h. Helping with chores:
VII. Who are doctors/medical providers most familiar with your need for home health services? VIII. Are there any friends/relatives who are familiar with your needs? IX. Have you filed an appeal with the Office of Administrative Hearings? YesNo
i. Did you ask that services be continued at the existing level during the appeal? YesNo
a. Have your services been continued at the existing level during the appeal? YesNo
ii. Do you have a hearing or status conference scheduled? If so, when?
Please note: You have 90 days from the date of the notice to file an appeal.
X. Is there anything else we should know about your case?
Even if you are a DC resident, we are unable to give you legal advice because your matter is a Maryland or Virginia one (depending on which state you selected), and we are not licensed to practice law in these states. However, please visit the Washington Lawyer’s Committee Workers' Rights Clinic for advice because they have attorneys licensed to practice law in Maryland, Virginia, and DC. DO NOT SUBMIT THIS FORM.
2. Where did you last work? (Name of Employer) Please select the option that best describes your issue:
I am having trouble applying for Unemployment InsuranceI applied for Unemployment Insurance and was deniedI receive or received Unemployment Insurance and have been charged with an overpayment
iv. Did you receive a final order in the mail? v.Did you appeal any unfavorable decision to the DC Court of Appeals within 30 days?
b. Why did your last job end? Did you quit, were you terminated, or were you laid off? c. Please describe in detail what happened before your last job ended. Did you get into any arguments with anyone, for example? d. What was your relationship with your co-workers and boss like? e. Did you ever receive any write-ups at your job for problems on the job? Did your employer ever threaten to give you a write-up? f. Did you ever receive any awards/promotions at your job for good performance?
F. Is DOES taking money out of your check to pay down the overpayment? YesNoI don't know G. Have you filed an appeal of the overpayment? YesNo H. Have you had a hearing at the Office of Administrative Hearings (441 4th St NW) about the overpayment? YesNo
I. Have you been sued in D.C. Superior Court (500 Indiana Ave NW) for the overpayment? YesNoI don't know
3. Is there anything else we should know about your case?
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If you have documents related to your issue, it can be helpful to us to see them to better understand your legal problem. Here are the kinds of documents that could be helpful in your case:
Social Security Overpayment
TANF (Temporary Aid for Needy Families) Food Stamps
Home Health Aide
Unemployment Insurance
I have no documents.I can upload some of my documents now.I have documents and will email them to onlineintake@legalaiddc.org. Please include your full name in the subject.I have documents and will fax them to Legal Aid at 202-727-2132. Please put to the attention of Online Intake on the cover sheet.I have documents and will mail them to Legal Aid. Please include your full name on the envelope and on the cover sheet (if any).
Please send the documents to the following address: Legal Aid Society of the District of Columbia Attn: Online Intake 1331 H St NW, Suite 350 Washington, DC 20005
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