9040014 ASSIGNMENTS OF INTEREST A This section provides information regarding the assignment of interest General of potential income sources in the GR Program B Whenever any applicantrecipient has a claim for a potential income Policy form receipt of proceeds from civil actions estate matters fishing catches farm crops insurance settlements or Workers Compensation a referral shall be made immediately to ORR to alert them of a potential source of GR repayment Referral for Assignment of Interest Form 115A HHSA shall be completed by the worker In addition the applicantrecipient shall be required to sign an Assignment of Proceeds Resulting from Pending Claims 115 HHSA for all assignments Failure to sign any of these forms shall result in GR denial or discontinuance The applicantrecipient shall be advised to report any change in the status of hisher claim for these lump sum benefits C Referral for Assignment of Interest Form 115A HHSA is selfexplanatory but be sure all information is recorded On the reverse enter all GR aid paid from the date of injury through the date of completion of the form The form shall be completed in duplicate Send one copy to ORR Mail Stop P60 Attention Judgment Services Section LN with other required forms or information attached Image the other copy in the case folder D Assignmentof Proceeds Resulting from Pending Claims Form115 HHSA This is an ORR lien which requires the applicant to assign to the County hisher rights to receipt of proceeds from successful civil actions insurance settlements Workers Compensation or other proceeds for aid given to the applicant The form blanks must be filled in and the document is required to be executed signed and dated Two original signatures are required to be executed A copy of the original can be provided to the applicant recipient The applicantsrecipients attorney should also sign the form but such signature is not required if the attorney refuses The two original signed forms shall then be attached to Form 115A HHSA and sent to ORR who will then follow up with collection activities