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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 6 OMB NO: 0960-0575 Date of Request
REQUEST TO RESOLVE QUESTIONABLE QUARTERS OF COVERAGE (QC)
Complete the information below when the QC array contains either a (#) pound sign or code “Z” prior to 1978. Mail the form and a copy of the system’s printout to the Social Security Administration, PO Box 17750, Baltimore, MD. 21235-0001.
Print Name:
Last First MI
SSN - -
Date of Birth ---------------------
MM DD YY Request Years 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 20 , 20 , 20 .
OR
19 thru 19 , 19 thru 19 , 19 , thru 19 ,
20 thru 20 .
State’s Name & Address
Contact Person’s Name & Telephone Number
The Paperwork Reduction Act of 1995 requires us to notify that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. SSA-512