Author: barinur
Last saved by: pellerp
Company: State of Florida

SSI/SSDI TIME LIMIT EXTENSION REVIEW FORM

The following individual has a disability application for SSI/SSDI
Participant’s Name (please print) | | RWB Designee Print  Name
RFA Case #/Category/Sequence | | DCF Unit Number
Section A:  To be completed by the Public Assistance Specialist (PAS)
How many months have the participant received temporary cash assistance? | | Months
How many months does the participant have left of their lifetime limit? | | Months
Comments:
Note:  If SSI/SSDI pending application verification is received, please attach and forward with this form to the Regional Workforce Board.
(DCF PAS Print Name) | | Phone Number | | Date
Address:
Section B:  To be completed by the Regional Workforce Board
Time Limit Extension: | | Approved | | Denied |
If approved, extension number: | | |
If appropriate, please check one of the following: | |
SSI/SSDI Approved: | | Date Approved? | | SSI/SSDI Denied: | | | Date Denied? |
In Appeal Process: | | Level of Appeal: | | Application current and verified: | | Yes | | No |
| | Date Application Filed: |
Comments:
Regional Workforce Board Designee Signature | | | Phone Number | | Date
Address:

DEO-WTP 2289, March 2013 (Replaces DEO-WTP 2289, October 2011)		Distribute copies to:  RWB Provider and DCF ESS

An equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. All voice telephone numbers on this document may be reached by persons using TTY/TDD equipment via the Florida Relay Service at 711.