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VIRGINIA DEPARTMENT OF SOCIAL SERVICES CASE RECORD TRANSFER FORM

10/24 VOLUME V, PART XXIV, PAGE 116

Case Record Transfer Form

FORM NUMBER - 032-03-0227

PURPOSE AND USE OF FORM - To communicate between local departments of social services when transferring responsibility for a case for program benefits from one locality to another. The form also serves as confirmation to acknowledge receipt of the case record.

NUMBER OF COPIES - Three.

DISPOSITION OF FORM - The BPS in the transferring agency must complete the names and addresses of the affected agencies and appropriate parts Section I of the form to address the types of assistance affected. The worker must prepare the case record for transfer to the new locality and send two copies of the form and case record to the receiving agency. The transferring agency must keep a copy of the completed form.

INSTRUCTIONS FOR PREPARATION OF FORM –

Complete the form with identifying information of the case and with the names and addresses of the agency from which the case is being transferred and the agency to which the case is being transferred. Complete Section I to identify the types of assistance and benefit amounts for the household. Add additional comments as needed. A representative of the transferring agency must sign the form.

A representative of the receiving local agency must complete Section II of the form to acknowledge the receipt of the case record. The agency must send copy of the completed form to the agency from which the case was transferred and keep a copy of the form.

TRANSMITTAL #35