108.81 Verification: Domestic Violence Verification Form (PA 1747)

An individual who requests a good cause waiver of a TANF program requirement based on domestic violence shall complete the Domestic Violence Verification Form ( PA 1747 ) provided by the CAO. The CAO will provide the verification form in person or by mail to an individual who requests the form (if it is safe to send mail to the individual) and will instruct the individual to provide verification that may include one of the following:

55 Pa. Code § 108.10

Section 1, Good Cause Claim must be completed by the individual. The individual can request to be excused from participating in certain TANF programs like RESET requirements because of DV. Certain TANF and ELRC program requirements may be waived if a requirement cannot safely be met due to past, present, or further risk of DV. Victims and survivors of DV may have the verification of certain eligibility factors waived, such as: identification, social security cards, employment, residency, and voluntary child support.

NOTE: The Bureau of Policy (BOP) reviews and approves waiver requests of requirements that the CAO cannot approve.

Any type of documentation listed on the PA 1747 , under Section 2, including law enforcement records, court records, medical/treatment records, social service records, child protective service records; or

Third party verification of the domestic violence from any of the entities or individuals listed in Section 3 of the form with knowledge of the circumstances which provide the basis for the waiver, including:

A domestic violence service provider;

A medical, psychological, or social service provider;

A law enforcement professional;

A legal representative; or

An acquaintance, friend, relative, or neighbor of the claimant, or other individual; or

If the individual is unable to safely obtain any of the items of evidence described in Sections 2 or 3 of the form, the client may self-affirm under Section 4 of the form that the individual cannot safely comply with a TANF program requirement(s) due to domestic violence.

CAOs must complete Section 5, Good Cause Claim Decision.

Documentation or third-party verification should be obtained, if possible, but self-affirmation will suffice to establish eligibility for a good cause waiver based upon domestic violence.

One verification form will suffice for one or more waivers.

The CAO may not, under any circumstance, have an individual who claims good cause based on domestic violence to do the following:

Contact the alleged abuser; or

Require the individual to obtain a Protection from Abuse Order (PFA) .

Such contact could endanger the safety of a victim /survivor , the family or household.