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STATE OF HAWAII BENEFIT, EMPLOYMENT DEPARTMENT OF HUMAN SERVICES AND SUPPORT SERVICES DIVISION DHS 1260 (REV 07/2023) Page 1 of 1 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) PROGRAM SELF-DECLARATION SCREENING FORM TO CLAIM DOMESTIC VIOLENCE STATUS I. DOMESTIC VIOLENCE (DV) STATUS: A family, who has at least one (1) member determined to be a DV survivor by the domestic violence advocacy (DVA) service provider, shall be eligible for DV status. The DV status shall be for a period of six (6) months and shall exempt the family from the five (5) year time limit and the 20% benefit reduction. In certain situations, the DV status may be extended for an additional six (6) month period. The family must comply with the DVA services and participation with the First-To-Work (FTW) program as a condition of eligibility. Failure to cooperate with DVA services and/or with the FTW program will result in the denial of the DV status and/or termination of the II. DV STATUS CRITERIA: Please answer the following questions. YES NO 1. Are you working 20 hour or more each week? 2. Are you attending school for more than 6 credit hours each week? 3. Is it difficult for you to go to work or attend school due to DV situation(s)? 4. What is your relationship to the alleged perpetrator? 5. Which of the following protective actions have you taken as the result of DV situation(s) involving the perpetrator? a) I have a current court order protecting me or a member of my family from the alleged perpetrator. b) I am a party to a pending divorce or custody action which involves issues of current or past DV situation(s). c) Within the past 12 months, I have stayed in a DV shelter. d) Within the past 12 months, I had to stay with a friend or relative to escape from a DV situation and my friend or relative is willing to provide a written statement attesting to the DV situation. e) Within the past 12 months, I or a member of my family is a survivor of a DV situation which resulted in the arrest, arraignment, or conviction of the alleged perpetrator. f) Within the past 12 months, I or a member of my family received inpatient or outpatient treatment for psychological, physical, or emotional abuse as the result of a DV situation. g) Within the past 12 months, I or a member of my family was hospitalized or received emergency room treatment for medical or psychological injuries resulting from a DV situation. h) Within the past 12 months, the alleged perpetrator threatened me or a family member with death or grievous bodily harm. III. APPOINTMENT WITH THE DVA SERVICE PROVIDER: Your DVA appointment is scheduled on: Date:

Time: Address:

Phone Number: Bring this form with you to the appointment and any of the supporting documents listed below to support your claim. If it is unsafe, the Department may send this form directly to the DVA service provider. If you need to reschedule this appointment, please call the DVA service provider above. IV. SUPPORTING DOCUMENTS: You will need to provide supporting documents to the DVA service provider so determination can be made whether your family is eligible for the DV status. The following are examples of supporting documents that you can provide: 1. Court documents 4. Medical records, discharge documents 2. Police reports/records 5. Written statement from your friend or relative with whom you sought 3. Letter/verification from a DV service provider shelter to escape from a DV situation You will be informed by the DVA service provider of the decision after your scheduled appointment. NOTE: If you do not want this written decision or any other DV information to be mailed to your home, please advise your DHS worker. DO NOT MAIL THIS TO MY HOME. V. ATTESTATION AND CLAIM: I have read this notice and understand the information it provides. I would like to claim the DV status. I agree to submit any necessary supporting documents to the DVA service provider. Print Applicant/Recipient Name Signature Date Case Number Applicant/Recipient Mailing Address Phone Number Name of Referring DHS Office Mailing Address Phone Number Fax Number FOR DVA SERVICE PROVIDER USE ONLY. Supporting Documents Received: 1. is approved for the period from to . 2. Client failed to submit document(s) to support the DV claim. The request for the DV status is denied. 3. Client submitted document(s) 4. The request for the DV status is denied because: Name of DVA Advocate Signature Date Phone Number Attachment B-3