137.54 Diversion Agreement Form (PA 1793)

The Diversion Agreement Form ( PA 1793 ) serves as the Agreement of Mutual Responsibility (AMR) for Diversion recipients. An applicant who only wants Diversion does not need to complete the TANF AMR ( PA 1661 ).

The following individuals must sign the Diversion Agreement Form: Anyone required to sign the Application for Benefits and required to sign the AMR to receive TANF. This includes ES budget group members who meet Diversion criteria; the payment name if different from the applicant; budget group members age 18 years or older; and those considered as emancipated minors.

NOTE: All Cash Assistance applicants who are required to complete a Diversion Agreement can opt to orally sign and initial appropriate sections telephonically. When the applicant chooses to orally sign the agreement form, the narrative must include the following statement: “[Applicant’s name] has orally signed the Diversion Agreement form and orally attested to: Understanding their responsibility and the acknowledgement statement.” If the applicant or other household members required to sign the agreement form opt out and choose to complete the Diversion Agreement form by mail, it must be returned within 30 days. If the applicant fails to return the signed Diversion Agreement form within 30 days, they must either reapply or request a reconsideration.

PURPOSE OF DIVERSION AGREEMENT

Document applicant’s informed decision regarding Diversion and TANF.

Document community services discussed with applicant .

CAO RESPONSIBILITIES

Explain eligibility requirements and objectives of Diversion Program.

Help applicant determine need for other services at the CAO.

Recommend community services beneficial to the applicant family.

APPLICANT RESPONSIBILITIES

Explain and verify short-term financial need and plans to support family without applying for TANF.

Use Diversion payment for specific financial need(s) presented in the application for Diversion.

Sign and date to acknowledge that the CAO explained the Diversion Program—and that the applicant understands, they are choosing a Diversion benefit not to exceed three months. This includes acknowledging that the applicant may not receive cash assistance during the Diversion period; may not receive another Diversion benefit for 12 months from the date the Diversion benefit authorization, as noted on the Notice of Eligibility; may keep any child support received during the Diversion period.