TN 19 (08-17)

A. When to use the SSA-4233

Use form SSA-4233 (Social Security Administration Transmittal for Supplemental Nutrition Assistance Program (SNAP) Application) to send the following to the local SNAP office:

• a completed SNAP application with supporting documentation received during the Supplemental Security Income (SSI) claim;

• a signed SNAP teleclaim; or

• additional information or documents received after the SNAP application is submitted.

IMPORTANT: Do not complete the SSA-4233 transmittal form until you get the signed application. However, the household always has the option of submitting the completed and signed application to the local SNAP office directly, instead of to the field office (FO).

B. How to complete the SSA-4233

Complete the form electronically from InForms. Although most of the questions on the SSA-4233 are self-explanatory, the instructions below provide additional guidance on how to complete the entries.

Complete the following contact information at the top of the transmittal form. Then complete Items 1 through 7.

• TO (local SNAP office address);

• DATE;

• FAX NUMBER (of SNAP office);

• FROM (FO address);

• SSA CONTACT;

• TELEPHONE NUMBER;

• NAME OF APPLICANT;

• APPLICANT SOCIAL SECURITY NUMBER (SSN);

• DATE APPLICATION FILED;

• EXPEDITED SERVICE REQUESTED; and

• IDENTITY AND RESIDENCY (for the head of household or authorized representative).

1. ITEM 1 - SSNs OF HOUSEHOLD (HH) MEMBERS

Indicate if all SSNs are recorded on the SNAP application or if SSNs for household members are not available. If SSNs for household members are not available, list the names of household members in the space provided. If the SNAP application was taken as part of a teleclaim, record household members’ SSNs that the applicant did not supply.

2. ITEM 2 - ALIEN STATUS

Select the appropriate box to indicate the alien information for all household members.

• If you receive proof of alien status, fax a photocopy of the evidence with the SSA-4233 transmittal form, even if a copy is in the supplemental security income (SSI) file.

• List the names of all household members who are alleged to be aliens but for whom you did not receive proof of alien status on the SSA-4233 transmittal form.

3. ITEM 3 - GROSS INCOME

Select the appropriate box to indicate if you received (or did not receive) proof of gross earned or unearned income for all household members. List the names of household members for whom you did not receive proof of income or for whom you have incomplete proof of income in the SSI file.

4. ITEM 4 - LIQUID RESOURCES

Select the appropriate box to indicate if you received (or did not receive) proof of liquid resources for all household members. List all names of household members who have unverified liquid resources or you have incomplete proof in the SSI file. Briefly describe the type of resource (e.g., a savings account) at issue.

5. ITEM 5 – UTILITY EXPENSES FOR HOUSEHOLD

Select the appropriate box to indicate if utility expenses (e.g., electricity, gas, water, or telephone bills) for the household are in the SSI file, not verified, not applicable, or if the evidence is attached to the SSA-4233 transmittal form.

6. ITEM 6 - MEDICAL EXPENSES

Select the appropriate box to indicate if medical expenses for household members age 60 or older, receive Social Security disability benefits, or SSI payments are in the SSI file, not verified, or not applicable. If the applicant provides copies of the medical expenses, provide an explanation along with the evidence (use Item 7, REMARKS section, if necessary).

7. ITEM 7 - REMARKS

Use this section to document information relevant to the SNAP application, supporting evidence, or attachments that you send to the SNAP office.

C. How to prepare and send the SSA-4233 transmittal form

Follow regional or local office procedures to route completed SNAP application packages or any subsequently submitted SNAP-related evidence. If no specific local procedures exist:

• place the documents in the following order: SSA-4233 on top, supporting evidence or documents next, and, if applicable, the SNAP application; and

• fax the SNAP application package or evidence to the local SNAP office.

IMPORTANT: Send the completed SSA-4233 transmittal form, along with the supporting documentation or SNAP application, to the SNAP office within one federal workday after you receive a signed application.