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VIRGINIA DEPARTMENT INTERIM REPORT FORM OF SOCIAL SERVICES REQUEST FOR ACTION

10/24 VOLUME V, PART XXIV, PAGE 69

INTERIM REPORT FORM – REQUEST FOR ACTION

FORM NUMBER – 032-03-0649

PURPOSE OF FORM – To notify a household of required actions it must take for completing the Interim Report or for providing required verification.

USE OF FORM – The BPS may use this form to tell households what action is needed to process the Interim Report to avoid closure of the case.

NUMBER OF COPIES – Two

DISPOSITION OF FORM – The BPS must notify households when they fail to complete the Interim Report form or fail to submit needed verification or information. If households file an incomplete form or fail to submit needed information, the BPS must return the original Interim Report to the household along with this action form. If households fail to file an Interim Report altogether, the BPS may send another copy of the report to the household along with the action form. Send the Interim Report Form-Request for Action by the 15th of the month the Interim Report was due if the household fails to return a completed Interim Report.

INSTRUCTIONS FOR PREPARATION OF FORM – Complete identifying case and agency information at the top of the form and the action required by the household. Sign and date the form.

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