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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES CHECKLIST OF NEEDED VERIFICATIONS
Name
Address
Case Number
Program(s)
Date
Worker
Telephone
FAX
In order for us to see if you are eligible for assistance, you must provide the information checked below. We will help you obtain the information. If you cannot provide the information, or if you need help in providing the information, contact your worker. Call collect, if necessary. If you do not provide this information or contact the agency by the following dates, your application may be denied.
TANF:
SNAP:
MEDICAID:
OTHER:
1. INCOME (Earned and Unearned)
for ________________________ ( ) Pay stubs ( )Statement from employer ( ) Self-employment records ( ) Social Security/SSI benefits ( ) VA benefits ( ) Retirement income ( ) Child support, alimony payments ( ) Unemployment benefits ( ) Worker’s Compensation benefits ( ) Loans (personal or education) (fl ) Scholarships, (BEOG, PELL
SEOG, CSAP, or other) ( ) Work-study pay stubs ( ) Other ________________________
2. WORK OR SCHOOL EXPENSES ( ) Day care expenses for child or adult ( ) School expenses (tuition, fees, books
supplies, transportation, or other) ( ) Other ________________________
3. RESOURCES ( ) Checking, savings, credit union,
Christmas Club account statements ( ) Stocks, bonds or CDs ( ) Pension plans, retirement
accounts, IRAs ( ) Burial plots, funds, contracts ( ) Real estate property ( ) Title, registration, or personal property
tax receipt for motor vehicles, motor
boats, motor homes ( ) Life insurance policies ( ) Other _______________________
4. SHELTER EXPENSES ( ) Rent or mortgage receipt ( ) Real estate taxes ( ) Homeowner’s insurance ( ) Electric bill ( ) Gas/Kerosene/oil/wood bill ( ) Water/sewage bill ( ) Garbage bill ( ) Phone bill ( ) Initial installation charge ( ) Other________________________
5. LEGALLY RESPONSIBLE
RELATIVE ( ) Income verification ( ) Statement of contribution ( ) Child support or alimony ( ) Extraordinary expenses ( ) Proof of continued absence ( ) Copy of support order ( ) Other _______________________
6. WORK REGISTRATION ( ) Registration information
7. IDENTITY ( ) Driver’s license ( ) Voter registration card ( ) Clinic, medical card ( ) Work ID, school ID, library card ( ) Other _______________________ 8. RESIDENCY, LIVING ARRANGE-
MENTS, SCHOOL ENROLLMENT ( )) Verification of residence ( ) Verification of child(ren)
living in the home ( ) School enrollment ( ) Separate arrangements to buy
and prepare food ( ) Other _____________________
9. DOCUMENTS ( ) SSN Cards/numbers ( ) Application for SSN card ( ) Declaration of citizenship ( ) Immigrant/Alien documentation ( ) Birth verification ( ) Verification of paternity ( ) Marriage certificate ( ) Divorce decree ( ) Death certificate ( ) Deprivation statement ( ) Other _____________________
10. MEDICAL INFORMATION ( ) Assignment of Rights form ( ) Medical form, statements ( ) Pregnancy statement ( ) Health insurance policies, cards ( ) Medicare card ( ) Health insurance premiums ( ) Medical bills for
( ) Prescription drug bills ( ) HIPP forms ( )) Immunization records ( ) Other _____________________ Other information or verification needed:_____________________________________________________________________
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032-03-0814-10-eng (9/11)