"Social Security Number Verification Form" - Colorado

Social Security Number Verification Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

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COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING
1570 Grant Street, Denver, CO 80203-1818
(303) 866-2993
(303) 866-4411 Fax
(303) 866-3883 TTY
John W. Hickenlooper, Governor
Susan E. Birch MBA, BSN, RN, Executive Director
Social Security Number Verification Form
Purpose Statement
Individuals who apply to public housing agencies for rental housing assistance must include
verification of social security number (SSN) per Department of Housing and Urban
Development (HUD) PIH 2012-10 (HA) issued February 14, 2012. Residents of nursing
facilities and/or institutions may not have access to birth certificate, social security cards or other
standard forms of identification that would provide this information.
HUD Notice PIH 2012-10 (HA) states that the public housing agency can accept an original
document issued by a federal, state, or local government agency, which contains the name and
SSN of the individual as acceptable evidence.
This document is issued by the Colorado Department of Health Care Polity & Financing (HCPF)
to verify the following individual’s SSN:
Individual Name _______________________________________
Social Security Number __________________________________
Date of Birth ___________________________________________
Date __________________________________________________
Authorizing Entity_______________________________________
Title __________________________________________________
Nora Brahe
Transitions Administrator
Long Term Care Reform Unit
Long Term Benefits Division
Department of Health Care Policy & Financing
303-866-3566
Fax 303-866-2786
norabrahe@state.co.us
colorado.gov/hcpf
COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING
1570 Grant Street, Denver, CO 80203-1818
(303) 866-2993
(303) 866-4411 Fax
(303) 866-3883 TTY
John W. Hickenlooper, Governor
Susan E. Birch MBA, BSN, RN, Executive Director
Social Security Number Verification Form
Purpose Statement
Individuals who apply to public housing agencies for rental housing assistance must include
verification of social security number (SSN) per Department of Housing and Urban
Development (HUD) PIH 2012-10 (HA) issued February 14, 2012. Residents of nursing
facilities and/or institutions may not have access to birth certificate, social security cards or other
standard forms of identification that would provide this information.
HUD Notice PIH 2012-10 (HA) states that the public housing agency can accept an original
document issued by a federal, state, or local government agency, which contains the name and
SSN of the individual as acceptable evidence.
This document is issued by the Colorado Department of Health Care Polity & Financing (HCPF)
to verify the following individual’s SSN:
Individual Name _______________________________________
Social Security Number __________________________________
Date of Birth ___________________________________________
Date __________________________________________________
Authorizing Entity_______________________________________
Title __________________________________________________
Nora Brahe
Transitions Administrator
Long Term Care Reform Unit
Long Term Benefits Division
Department of Health Care Policy & Financing
303-866-3566
Fax 303-866-2786
norabrahe@state.co.us
colorado.gov/hcpf
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