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VIRGINIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF EXPIRATION

10/24 VOLUME V, PART XXIV, PAGE 53a

NOTICE OF EXPIRATION

FORM NUMBER - 032-12-0157 (The version presented here may not match the version prepared monthly through VaCMS with specific case information. This version may be used manually by the BPS.)

PURPOSE OF FORM - To advise the household (1) that its certification period is about to expire; and, (2) that a new application is necessary to establish further entitlement.

USE OF FORM - Households approved in the last month of their certification period, i.e., households certified retroactive to a previous month(s), must be provided the expiration notice at the time of certification. All other households must have the expiration notice no later than the last day of the next to the last month of the current certification period, but not earlier than the first day of the next to the last month of the current certification period. Allow two days for delivery in addition to the postmark date when the form is mailed.

NUMBER OF COPIES - Two

DISPOSITION OF FORM - The agency must give or mail the completed Notice of Expiration to the household and retain a copy.

INSTRUCTIONS FOR PREPARATION OF FORM - Complete all blanks.

Below the agency's address, enter the date the certification period will end, which is the last day of the last month of certification. Enter an alternate address for the agency at the bottom of the form, if appropriate.

Enter the date by which the household must file an application for recertification. For households approved in the last month of their certification period, this will be 15 calendar days from the date the notice will be received. (Allow two days for mailing in addition to the postmark date.) For all other households, this will be the 15th calendar day of the last month of certification.

Indicate whether the form was mailed or given to the recipient on the date indicated.

Enter information regarding an interview date and time.

TRANSMITTAL #35