Form ADSA 1B Assistance Dog Special Allowance (Adsa) Application for Social Security Disability Insurance (Ssdi) Recipients - California

Form ADSA1B or the "Assistance Dog Special Allowance (adsa) Application For Social Security Disability Insurance (ssdi) Recipients" is a form issued by the California Department of Social Services.

Download a fillable PDF version of the Form ADSA1B down below or find it on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ASSISTANCE DOG SPECIAL ALLOWANCE (ADSA) APPLICATION FOR
SOCIAL SECURITY DISABILITY INSURANCE (SSDI) RECIPIENTS
Department of Social Services - Office of Services to the Blind
744 P Street, MS 8-16-94, Sacramento, CA 95814
Phone: (916) 657-2628 / TTY: (916) 651-6248
PERSONAL INFORMATION
Name (First, Middle, Last)
Birthdate
Zip code
City
Home address
Mailing address (if different)
Home phone
Message phone
(
)
(
)
Are you?
Deaf/Hard of Hearing
Blind/Visually Impaired
Other disability (specify):_________________________________
Persons residing in household
Social Security Number
Medi-Cal card number (if any)
(other than spouse)
Current Marital Status:
separated
single
married
widowed
divorced
Do you reside in California?
Yes
No
Do you have a:
Dog’s name
Date acquired
Guide dog
Signal dog
Service dog
What person or school trained the dog?
Their area code and phone number is:
(
)
What service does the dog provide?
ADSA 1B (1/10)
PAGE 1 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ASSISTANCE DOG SPECIAL ALLOWANCE (ADSA) APPLICATION FOR
SOCIAL SECURITY DISABILITY INSURANCE (SSDI) RECIPIENTS
Department of Social Services - Office of Services to the Blind
744 P Street, MS 8-16-94, Sacramento, CA 95814
Phone: (916) 657-2628 / TTY: (916) 651-6248
PERSONAL INFORMATION
Name (First, Middle, Last)
Birthdate
Zip code
City
Home address
Mailing address (if different)
Home phone
Message phone
(
)
(
)
Are you?
Deaf/Hard of Hearing
Blind/Visually Impaired
Other disability (specify):_________________________________
Persons residing in household
Social Security Number
Medi-Cal card number (if any)
(other than spouse)
Current Marital Status:
separated
single
married
widowed
divorced
Do you reside in California?
Yes
No
Do you have a:
Dog’s name
Date acquired
Guide dog
Signal dog
Service dog
What person or school trained the dog?
Their area code and phone number is:
(
)
What service does the dog provide?
ADSA 1B (1/10)
PAGE 1 OF 4
RESOURCE INFORMATION
(1) Do you or your spouse own real property other than your home?
Yes
No
(If “Yes”, give the information below)
Address
City
Zip code
Total amount owed on mortgage
Monthly payment
Assessed value
$
$
$
Annual taxes
Annual insurance
$
$
How is property utilized?
Other property expenses
(2) Do you or your spouse own motor vehicles (cars, trucks, motorcycles, boats,
motorhomes)?
Yes
No
(If “Yes”, give the information below)
Check (✔) if used for
Make and
Estimated
Modified for
Year
Medical
Work
Model
Value
Disabled Persons?
Transportation
(3) List the value of your liquid resources below:
(Indicate if any resource is exclusively for burial expenses for your immediate family.)
(X) for
(X) if
Enter value under owner
Self
Spouse
Jointly
Burial
None
Cash on hand and/or
money kept in home
$
$
$
Checking account
$
$
$
Savings account, credit
union, trust funds
$
$
$
Checks or cash in
safety deposit box
$
$
$
Stocks, bonds or
mutual funds, notes,
mortgages, deeds
$
$
$
IRA, certificates of
deposit, money market
$
$
$
Other (specify):
$
$
$
PAGE 2 OF 4
INCOME INFORMATION
List income received each month:
Enter monthly amount received by:
(X) if
None
Self
Spouse
Earned gross income (All sources)
$
$
Unearned gross income
$
$
Social Security Disability Insurance (attach
a copy of your SSDI Certificate of Award)
$
$
Supplemental Security Income/State
Supplementary Payment (SSI/SSP)
$
$
Social Security Retirement Benefits
$
$
State Disability/Unemployment Insurance
$
$
Veteran’s Pension/Compensation
$
$
Other Government Pension or Retirement
$
$
Private Pension or Retirement
$
$
Alimony
$
$
Rental Income
$
$
Interest, dividends, royalties
$
$
Worker’s Compensation
$
$
Other (specify):
$
$
Total:
$
$
PAGE 3 OF 4
Be sure you have read and understood every item and answered all the questions that
apply to you. Read the following information carefully before signing.
I understand and agree that I must tell the California Department of Social Services within
10 days if there is any change in any of the information provided on this application.
I agree to meet all other responsibilities explained in the ADSA 3 form, which was
furnished to me with this application.
I understand and agree to provide, upon request, information or documents to prove the
information I have provided here is true and correct. The State is required by law to keep
this information confidential.
I understand that if I am dissatisfied with any actions taken by the California Department of
Social Services, I have the right to a State Hearing.
I declare under penalty of perjury, subject to prosecution as the crime of perjury under
the Penal Code, that the information given on this application is true and correct.
Signature of applicant
Date
Signature of witness (required if applicant signed by mark)
Date
Signature of person helping applicant complete form
Date
PAGE 4 OF 4

Download Form ADSA 1B Assistance Dog Special Allowance (Adsa) Application for Social Security Disability Insurance (Ssdi) Recipients - California

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