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AGENCY USE ONLY CASE NAME CASE NUMBER LOCALITY

SCREENER DATE

EXPEDITED SERVICE DETERMINATION Income < $150 + resources ≤ $100  YES  NO Income + resources < shelter bills  YES  NO

For migrant or seasonal farm workers:

Resources ≤ $100 and ≤ $25 is expected in next 10 days from new income;  YES  NO

OR

Resources ≤ $100 and $0 income is expected from a terminated source for the rest of this month or next month.  YES  NO

EXPEDITE IF YES TO ANY OF THE ABOVE.

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