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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 7
Date of Request
QMB NO: 0960-0575
REQUEST FOR QUARTERS OF COVERAGE (QC) HISTORY BASED ON RELATIONSHIP
Complete the information below when requesting QC history for spouse(s) or parent (s) of a lawfully admitted non-citizen applicant. Mail the form to the Social Security Administration, PO Box 17750, Baltimore, MD 21235-0001.
Print Name:
Last First MI
SSN
- -
Date of Birth ----------------------------
MM DD YY Relationship to Applicant
NOTE: COMPLETE THE YEAR COLUMN AND CIRCLE THE PERTINENT QUARTER (S) FOR THE YEAR. SSA WILL PROVIDE INFORMATION ONLY FOR YEARS AND QUARTERS YOU INDICATE.
QC PATTERN QC PATTERN YEAR 1ST Q 2nd Q 3RD Q 4TH Q YEAR 1ST Q 2nd Q 3RD Q 4TH Q
State’s Name
& Address
Contact Person’s Name & Telephone Number
FORM SSA-513 (9/97)