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Concord California Form Instructions 709: What You Should Know

Medical verification form. ​ We can give you a new Social Security Number (SSN), or you may be eligible for a Social Security Disability Leave (SSD) In order for it to be accepted, your spouse must have a current SSN or a recent letter ​ (1) If you are an employee, please contact the state to notify Social Security of your ​ employment status. ​ ​ ​ ​ ​ ____________ ​​ If your filing status is divorced, legally separated or not married and separated, you ​ should contact the Department of Family and Support Services (DFS). You will need to ​ provide documentation showing ​ ​ ​The Social Security Administration has determined that you are eligible for SSD. ​ ​ ​ ____________ ​​ ​ ____________ ​ ____________ ​ ____________ ​ ____________​ ​​ ____________ ​​ ____________ ​ ____________​ ​ ____________ If you are an employee, please check with your company to determine if you will be eligible for ​ ​ Disability Leave.  ​ When you have an SSD, your spouse may no longer be eligible for Medicaid or ​ SSI benefits if you work at an SSA agency or a state program. ​ Please be advised that you will receive notice on your monthly SSD disbursements as to when ​ or if you will be eligible for SSD. Please keep this notice for your records as it will help ​ you if you are later asked to provide SSN verification for another tax ​ payment or for any state benefit program. ​ ​  ​ ​ ____________ ​ ____________ We believe that you should not need to contact us before or while claiming ​ a tax credit or refund. If you are the victim of identity theft or if your Social ​ Security number has been stolen, you could lose your benefits if you ​ contact us before claiming any tax credits or refunds.

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