Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
Date:If you need help filling out this form please ask for help at your local Department of Human
Services (DHS) Office.
Eligibility for the SFPSS program
You may be eligible for the State Family Pre SSI/SSDI if you:
Are an adult and have a child under 18 living with you, and
Are eligible for and receive Temporary Assistance for Needy Families (TANF), cash assistance,and
Have a disability which prevents you from working.
Submitting Instructions
Applicant:
Complete the form and do one of the following
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
► Email the form to:
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
►Drop the form off at your local DHS office
►Mail the form to:
SFPSS – CAF
3420 Cherry Ave. NE, Suite 140
Salem, Oregon97303
Local Office (DHS and community partners only):
If you receive a DHS 7816, “Self Referral Form,” please fax the form to:
►503-393-1867 – Attention SFPSS
If you are helping someone fill out the form online you can:
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
►Email the form to: form can also be sent using the Outlook system. The address is: CAF SFPSS
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
►Print and fax the form to: 503-393-1867– Attention SFPSS
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
Date: / District:Branch: / Prime number: / Case number:
Name: / Date of birth:
Address:
City: / State: / ZIP code: / Phone:
Email address:
Are you receiving help from the Department of Human Services (DHS)? / Yes No
If you are receiving help from DHS, do you know the name of the office? / Yes No
I receive help from the DHS branch (name of branch):
Do you have a medical condition that is expected to last 12-months or more? / Yes No
Does the condition prevent you from working? / Yes No
Information you want to add:
Local office (DHS and community partners only):
If you receive a DHS 7816, “Self Referral Form,” please fax the form to:
►503-393-1867 – Attention SFPSS
If you are helping someone fill out the form online you can:
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
►Email the form to: form can also be sent using Outlook system. The address is: CAF SFPSS
Page 1 of 3 DHS 7816 (02/12)
/ Online form can be found at:Click on “Find a DHS Form.” Enter 7816 in the top search box.
State Family Pre SSI/SSDI Program (SFPSS) Self-Referral
►Print and fax the form to: 503-393-1867 – Attention SFPSS
The Department of Human Services (DHS) will not discriminate against anyone. This means DHS will help all who qualify. DHS will not deny help to anyone based on age, race, color, national origin, sex, sexual orientation, religion, political beliefs or disability. You can file a complaint if you think DHS discriminated against you for any of these reasons.
“Equal Opportunity is the Law”
Auxiliary aids and services are available upon request to individuals with disabilities.
Page 1 of 3 DHS 7816 (02/12)