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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES
CASE RECORD TRANSFER FORM
TO: DEPARTMENT OF SOCIAL SERVICES
FROM: DEPARTMENT OF SOCIAL SERVICES
___________________________________________________ ___________________________________________________ COUNTY/CITY
COUNTY/CITY ___________________________________________________ ___________________________________________________ ADDRESS
ADDRESS
I. TRANSFERRING LOCALITY CASE INFORMATION
CASE NAME _______________________________________ CASE NUMBER____________________________________
MOVED TO YOUR LOCALITY ON ____________________________________ AND IS RESIDING AT _______________________________
_______________________________________________________________________________________________________________________
UNIT MEMBERS ________________________________________________________________________________________________________
TYPE OF ASSISTANCE:
TANF VIEW CASE TANF NON-VIEW CASE REFUGEE CASH ASSISTANCE OTHER _____________________
AMOUNT OF PAYMENT ____________________________
LAST PAYMENT MONTH __________________________________
VERIFICATION OF ______________________________________ NEEDED BEFORE ISSUANCE OF ___________________ BENEFITS
SNAP Benefits
CERTIFICATION PERIOD END DATE / /
VERIFICATION OF ______________________________________ NEEDED BEFORE ISSUANCE OF ___________________ BENEFITS
PENDING MEDICAID
RECEIVING MEDICAID RECEIVING REFUGEE MEDICAL ASSISTANCE
RECEIVING FAMIS (APPLICATION, EVALUATION, INCOME VERIFICATION, AND NOTICE OF ACTION ATTACHED)
ADDITIONAL REMARKS:
SIGNATURE (AGENCY REPRESENTATIVE) ________________________________________________________ DATE: _______________________
PRINTED NAME______________________________________________________________ TITLE: ___________________________________
II. CONFIRMATION OF RECEIPT & DISPOSITION
CASE RECORD WAS RECEIVED ___________________________________________ DETERMINED: ELIGIBLE INELIGIBLE
EFFECTIVE
/ /
FOR
DATE
TYPES OF ASSISTANCE
ADDITIONAL REMARKS
SIGNATURE (AGENCY REPRESENTATIVE) ________________________________________________________ DATE: _______________________
PRINTED NAME______________________________________________________________ TITLE: ___________________________________
032-03-0227-10-eng (10/09)