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VIRGINIA DEPARTMENT OF SOCIAL SERVICES RIGHTS AND RESPONSIBILITIES

10/24 VOLUME V, PART XXIV, PAGE 119

Compromising Claims Worksheet

FORM NUMBER - 032-03-0572

PURPOSE AND USE OF FORM – May be used to document how all or a portion of a claim amount owed may be eliminated to allow a household to repay the debt within three years.

NUMBER OF COPIES - One.

DISPOSITION OF FORM – The worksheet or other documentation must be filed with the claim information to document why the claim amount owed was or was not reduced or eliminated through compromising.

INSTRUCTIONS FOR PREPARATION OF FORM – A local agency representative must complete the identifying case/claim information. The representative must provide the worksheet to the household to complete the information about household income, resources, and expenses. Calculate the entitlement for compromising the claim in the bottom section of the worksheet by using the information supplied by the household.

TRANSMITTAL #35