Public Benefits Intake

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Section A: Basic Information Please provide the following basic information, which will be used to perform a conflicts check. If we are unable to assist you based on this information, we will not review and will not enter into our system any information from the following sections.

* indicates a required field.

WhiteBlackHisp./LatinoAsianPacific Island.Native Amer.Biracial/MultiracialPrefer Not to AnswerOther
FemaleMaleGender NonconformingPrefer Not to AnswerOther:
By applying for legal assistance online you are agreeing to be contacted by all methods. If you prefer not to be contacted by these methods please call the intake line at 202-628-1161. Press option 1, then press option 2.








Section B: Income Information
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.

Type of Income*
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency

Tip: If no one in your household receives any form of income, please select the option that says “My household has zero income” in the first drop-down box.

If you are unsure about what kind of income you receive, or you want to give us additional information, please use the box below.
Section C: Information about your Legal Matter
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
SOCIAL SECURITY I applied for Social Security and was denied (Note: If you applied and have NOT yet been denied, then please do not complete an online intake application right now. Instead re-apply for our help if/when you are denied.)I was receiving Social Security benefits, but they were reduced/terminated.I receive or received Social Security and have been charged with an overpayment.
I. What type(s) of Social Security benefits did you apply for? (i.e., SSI, child SSI, SSDI, widow's benefits, survivor’s benefits, etc.)

II. Are you asking for help with a Request for Reconsideration appeal (first level of appeal) or a Hearing appeal (second level of appeal)?

Please see this chart for help figuring out if you have a Request for Reconsideration or Hearing appeal. Also, if you need help with a hearing appeal, click here for information on how to prepare for your hearing.


III. What is the date on the most recent Social Security denial notice you received?

IV. Did you file an appeal within 65 days of the most recent denial? YesNo

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

Why did you miss the deadline? (problems with mail, in hospital, homeless, etc.)

I. What type of benefits were you receiving? SSI, Child’s SSI, SSDI, Survivor’s benefits, etc.

II. Did you ask to have your benefits continue pending your appeal? 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:
  1. Employer Name
  2. Around when did the job begin and around how long did it last (a few months? A year? Longer than a year)?
  3. Job Title
  4. What were your job duties?
  5. Why did the job end?

VIII. Is there anything else we should know about your case?
A. What is the amount of the overpayment?

B. Did you receive a notice from Social Security about the overpayment? If not, how did you find out about the overpayment?

C. If you were given a reason for the overpayment, what was it?

D. Do you agree with Social Security’s explanation? If not, what do you think Social Security got wrong about the overpayment?

E. If Social Security claims that you failed to report other income:

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
Do you also have Medicaid or QMB?

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

Please review this self-help packet for dealing with Social Security overpayments. Please note that you have 60 days (from the date of the overpayment notice) to file a reconsideration appeal if you disagree that the overpayment occurred or think Social Security has the wrong amount.

I. Is there anything else we should know about your case?
TANF
1. How much TANF do you currently receive? For how many family members?

2. What problem are you having with TANF? TANF stopped (or about to be stopped)TANF was reduced (or about to be reduced)TANF application deniedApplied for TANF, but haven’t heard anything

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?
Food Stamps
1. How much in Food Stamps are you currently receiving each month? For how many household members?

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 did your benefits stop?

b. Did you get any notice about your benefits stopping? If so, what did it say?

c. How much were you getting before your benefits stopped?



a. When were your benefits reduced?

b. Did you get any notice about your benefits being reduced? If so, what did it say?

c. How much were you getting before your benefits were reduced?



a. When did you apply?

b. Did the Department of Human Services (DHS) say why you were denied?

c. Do you disagree with their decision?



a. 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. For example, proof of income, proof of rent, proof of residency, children's birth certificate, proof of bank account, or other resources.

Why not?


4. Did you appeal? YesNo

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.)



Is there anything else we should know about your case?
Medicaid/Medicare/QMB/Alliance My health insurance got cut off.I cannot get Medicaid/Medicare/QMB/Alliance to cover a procedure or drug I need.I have medical bills I cannot pay. 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:
  • Medicare cards are red, white, and blue and have a “claim number” (usually a random mix of numbers and letters);
  • Medicaid cards are either blue or white and say “DC Medical Assistance,” OR have the name of a managed care organization on them (Amerihealth, Trusted, MedStar Choice);
  • QMB cards say “Qualified Medicare Beneficiary” on them; and
  • Alliance cards are from a managed care organization (Amerihealth, Trusted, MedStar Choice) AND say Alliance on them.


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

a. Do you have a hearing date?

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

a. What medical procedure or thing is not being covered?

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

As a first step, please call your provider and tell them about your insurance to see if this resolves the problem.



Is there anything else we should know about your case?
Home Health Aide
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?
Unemployment Insurance
1. Where was your last job located? Note: If your last job was split between states, then where was your job mostly located? DCMDVAAnother state
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.
Even if you are a DC resident, your unemployment insurance case is located in the state where you worked. Therefore, you will need to talk to a lawyer licensed to practice law in that state. To find legal assistance in another state, please visit https://www.lawhelp.org/
2. Where did you last work? (Name of Employer)

Please select the option that best describes your issue:
I applied for Unemployment Insurance and was denied (Note: If you applied and have NOT yet been denied, then please do not complete an application and re-apply for our help if/when you are denied.)I receive or received Unemployment Insurance and have been charged with an overpayment.

a. Have you (or the employer) appealed the decision? Please note: the deadline for appealing these decisions is 15 calendar days from the date on the notice. YesNo
i. Has a hearing date been scheduled? This usually happens 2-3 weeks after an appeal is filed. YesNo
ii. What is the date of your hearing?

If you already had your hearing, then please answer these additional questions: iii. What was the outcome?

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?
A. What is the amount of the overpayment?

B. Did you receive a notice from the D.C. Department of Employment Services (DOES) about the overpayment? If not, how did you find out about the overpayment?

C. If you were given a reason for the overpayment, what was it?

D. Do you agree with the explanation? If not, what do you think the agency got wrong about the overpayment?

E. Did DOES claim that you failed to report other income? YesNoI don't know

i. What is the source of the other income?

ii. Did you get the income DOES thinks you did? YesNo

iii. Did you report income to DOES? If so, how?

iv. Did you report income when it was received, or did you report it later? If later, how much later -- after DOES told you you were overpaid?
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. What happened at the hearing? What did the judge decide?
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?
Section D: Documents
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:

Disability/Social Security/SSI
  • All Social Security notices and paperwork
  • All Medical Records

Social Security Overpayment
  • Any documents from the Social Security Administration (SSA), especially those explaining what the overpayment is for.
  • Any documents you gave to SSA, including any statements you made, and appeal paperwork you filed (ex: Request for Reconsideration or Request for Waiver of Overpayment Recovery).

TANF (Temporary Aid for Needy Families)
Food Stamps
  • Any papers you received from DHS
  • Any papers you gave to DHS
  • Any other papers you think are relevant
Medicaid/Medicare/QMB/Alliance
  • Copy of health insurance card(s)
  • Any notices you got from DHS about your health insurance
  • Any medical bills

Home Health Aide
  • Notices / decision letters
  • Medical records
  • Other relevant documents that you have

Unemployment Insurance
  • Any documents from the DC Office of Employment Services (DOES), including anything you gave to them
  • Any documents from the Office of Administrative hearings, including anything you gave to them
  • Any documents from D.C. Superior Court, including anything you gave to them
  • Any other documents related to your unemployment insurance case
Please let us know if you have any relevant documents, and, if so, how you would like to provide them to us.
I have no documents.I can upload some of my documents now.I have documents and will drop them off in person at Legal Aid (1331 H Street NW, Suite 350, Washington, DC 20005; M 9am-6pm, T-F 9am-5pm).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 202-727-2132. Please include your full name on the cover sheet.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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