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9. EXPENSES
SHELTER EXPENSES Y N
DAY CARE EXPENSES Y N CHILD SUPPORT DEDCUTION Y N TYPE OF EXPENSE MO. AMT. VERIFCIATION
MBR MO. AMT. DESCRIPTION VERIFICATION RENT/MORTGAGE
ELECTRICITY
GAS/KEROSENE/COAL OIL/WOOD
WATER/SEWER
GARBAGE
INSTALLATION
TAX/INSURANCE
MEDICAL EXPENSES Y N
MBR
MO. AMT.
DESCRIPTION, VERIFICATION, METHOD OF DEDUCTION
UTILITY STANDARD Y N 1-3 4+ PHONE STANDARD Y N HOMELESS STANDARD Y N
REASON FOR ENTITLEMENT TO STANDARD:
10. GENERAL RELIEF (MAINTENANCE)
11. EMERGENCY ASSISTANCE ( ) GR ( ) TANF-EA
Period of Unemployment
Applied for SSI
Decision appealed
Release of SSI check signed
Modified Standard
Full Standard
Reason for Standard
Date and Reason for Emergency:
Assistance Previously Received Y N
Date and Amount Received:
12. STATE AND LOCAL HOSPITALIZATION MBR
Services Dates
Provider Name
Applied within 30 days?
Y N
13. DIVERSIONARY ASSISTANCE PROGRAM
Loss/Delay of Income Y N TANF Requirement Met? Y N
Emergency Need $ Type
TANF $
Payment $ Date Issued (Max 4 months)
Vendor Payment Issued to:
TANF Period of Ineligibility:
Diversionary Assistance Ineligibility (60 mos.) Ends:
Acceptance Signed: Y N Date:
EVALUATION:
14. SPEND-DOWN CALCULATION
COUNTABLE INCOME $ $ $ SPEND-DOWN PERIOD:
FROM
TO
MINUS INCOME LEVEL
Person(s) on Spend-down:
EXCESS INCOME
Person(s) on Spend-down:
BENEFIT PROGRAMS
SNAP
MEDICAID 15. DISPOSITION DATE GIVEN: BOOKLET
HOTLINE
HANDBOOK
PROGRAM
DISPOSITION (Denial Resources)
EFFECTIVE DATE/ CERT/COVERED PERIOD
HH/AU SIZE
MONTHLY BENEFITS
PRORATED BENEFITS
SIGNATURE AND DATE (WORKER/SUPERVISOR)
4