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Commonwealth of Virginia Department of Social Services

1. GENERAL INFORMATION PROGRAM APPLICATION DATE INTERVIEW DATE CASE NAME

CASE NUMBER

SECONDARY CASE NAME

SECONDARY CASE NUMBER

IDENTITY (NAME)

VERIFICATION

HEAD OF HOUSEHOLD ADULT PARENT/PARENTAL CONTROL? Y N DESIGNATED BY HH AGENCY

FACE-TO-FACE INTERVIEW Y N IF NO, REASON:

Telephone Interview? Y N

ADDRESS

SECONDARY ADDRESS TYPE

INSTITUTIONAL STATUS Date

NF CBC ACR

VERIFICATION/REMARKS

VIRGINIA Y N RESIDENT? ACR/AFC RATE:

DMAS-96 Y N

SAR Y N

2. MEMBER INFORMATION

HH/UNIT MEMBERSHIP CHECK () IF INCLUDED PERMANENT VERIFICATIONS CHECK () IF REQ. MET SNAPET/ESP/VIEW REGISTRATION OR REFERRAL ATENDING SCHOOL? DEPRIVATION (MED – ONLY EFF 7/1/99) IMMUNIZATION REQUIREMENT MET? NAME OR MBR#

SNAP TANF MED AG MEDICAID/AG CATEGORY OTHR (LIST) SSN DOB CIT REL IF YES, DATE IF NO, REASON DOCUMENT TRUANCY GIVE REASON GIVE VERIFICATION

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

NAME

PROGRAM

REASON FOR EXCLUSION, DISQUALIFICATION OR INELIGIBILITY

TIME PERIOD

ASSIGNMENT OF RIGHTS

Y N NOTICE OF COOPERATION AND GOOD CAUSE SIGNED? Y N GOOD CAUSE CLAIMED? Y N

IDENTITY EXCEPTION CLAIMED: Y N LIVING WITH SPECIFIED RELATIVE/GUARDIAN Y N DEPRIVATION, TRUANCY, PREGNANCY, CONCEPTION/DELIVERY DATE, FOSTER CARE/ADOPTION STATUS, DISABILITY/BLINDNESS OR OTHER DOCUMENTATION

032-03-0823-11-eng (10/09) 1 EVALUATION OF ELIGIBILITY