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VIRGINIA DEPARTMENT OF SOCIAL SERVICES RIGHTS AND RESPONSIBILITIES

10/24 VOLUME V, PART XXIV, PAGE 117

Rights and Responsibilities

PURPOSE AND USE OF FORM – May be used to document that an applicant was provided written and verbal guidance on rights and responsibilities for applying and receiving public assistance benefits.

NUMBER OF COPIES - One.

DISPOSITION OF FORM – The case file must contain documentation that the local agency provided each applicant with information about the rights and responsibilities for applying and receiving public assistance benefits. The agency must present the information in writing and verbally. Written information is included as part of the benefit application forms. Applicants must acknowledge receipt of the rights and responsibilities information.

The local agency may use the Rights and Responsibilities form to have an applicant acknowledge receipt of rights and responsibilities information or to document that information was provided during a telephone interview or other contact with an applicant.

INSTRUCTIONS FOR PREPARATION OF FORM –

The applicant must complete the top portion of the form to acknowledge receipt of rights and responsibilities information in writing or verbally. The applicant must sign and date the form.

The local agency worker who provides the verbal presentation must complete the bottom portion of the form to acknowledge that rights and responsibilities information was presented. The worker must record the name of the applicant or other household member with whom a telephone interview was conducted and record the date the information was provided. The worker must sign and date the form.

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