Page 523

VIRGINIA DEPARTMENT OF SOCIAL SERVICES EVALUATION OF ELIGIBILITY

10/24 VOLUME V, PART XXIV, PAGE 31

EVALUATION OF ELIGIBILITY

FORM NUMBER - 032-03-0823

PURPOSE OF FORM - To document verification of elements used to determine eligibility and to document eligibility decisions.

USE OF FORM – May be completed by the BPS at application and review.

NUMBER OF COPIES - One.

DISPOSITION OF FORM - The form is to be kept in the case record.

INSTRUCTIONS FOR PREPARATION OF FORM - Complete the elements required for the program. If an element section is not appropriate for the program, mark Not Applicable (NA). If an entire section does not apply, leave the section blank.

Complete the disposition section to summarize the eligibility decision. The form must be signed by the BPS and should be signed by the supervisor, if a review of the action is completed.

TRANSMITTAL #35