APPENDIX C-3
CHECKLIST FOR CASE ACTIONS
The following sections provide checklists of common forms and actions that need to be completed for specific case circumstances such as taking a TANF application, completing a FS recertification or adding a newborn to a group.
I. TAKING AND PROCESSING A TANF APPLICATION
I-1: Forms that must be completed or given to applicant:
___Generic Application
___Checklist for Customer
___Preliminary Assessment
___Dictation Sheet
___Voter Registration (If Applicable)
___TANF Work Activity Referral (If Applicable)
___1400 Notice to Applicants
___1288 Notice to Child Support
___IV-D Partnership Agreement
___1549 School Form (If Applicable)
I-2: Information to collect from applicant
___Living with Verification (Two (2) Verifications Needed)
___Residency Verification (Unless Homeless)
___Asset Verification
___Income Verification
___Relationship Verification
___Enumeration Verification
I-3: Actions to Be Taken:
___Explain EPSDT
___Check Interface Screen Before Terminating Interview
___Discuss Work Requirements and Sanctions
___Discuss Child Support Requirements, Good Cause for Non-cooperation, and Sanctions
___Discuss Requirement That Changes Be Reported
II. TANF REDETERMINATION
II-1: Forms that must be completed or given to recipient:
___Recertification Form
___Checklist (If Applicable)
___1052 Record of Case Action
___TANF Work Activity Referral (If Applicable)
___If Recertifying for Food Stamps, Use Expedite Form
___Child Care Expense Form (If Applicable)
II-2: Information to Collect from Recipient:
___School Verification (If Applicable)
___Residency Verification
___Income Verification
___Asset Verification
II-3: Actions to Be Taken:
___Check Interface Screen Before Terminating Interview
___Discuss Work Requirements and Sanctions
___Discuss Child Support Requirements, Good Cause for Non-cooperation, and Sanctions
___Discuss Requirement That Changes Be Reported
III. TAKING AND PROCESSING A FOOD STAMP APPLICATION
III-1: Forms that must be completed or given to applicant:
___Generic or Food Stamp Only Application
___Checklist to Be Given to Customer
___26 Expedite Form
___1400 Notice to Applicants
___FSET-1 Employment - Training Referral (Done Every 12 Months)
___1052 Record of Case Action
___FNS 387 Food Stamp Change Report Form
___Photo ID Referral (If Applicable)
___Voter Registration (If Applicable)
III-2: Information to Collect from Applicant:
___Living with Verification (If Questionable)
___FS Shelter Cost Verification
___Child Care Expense Verification
___Residency Verification (Unless Categorically Eligible)
___Asset Verification (Unless Categorically Eligible)
___Earning Verification (Unless Categorically Eligible)
___Unearned Income Verification (Unless Categorically Eligible)
III-3: Actions to Be Taken:
___Check Interface Screen Before Terminating Interview
___Discuss FSET Requirements and Sanctions
___Discuss Requirements That Changes Be Reported, Including Simplified Reporting If Applicable
IV. FOOD STAMP RECERTIFICATION
IV-1: Forms that must be completed or given to recipient:
___Expedite Forms
___Generic Recertification Form
___FNS 387 Food Stamp Change Report Form
___1052 Record of Case Action
___FSET-1 Employment Training Referral (Every 12 Months)
___Voter Registration (If Applicable)
IV-2: Information to Collect from Recipient:
___Living with Verification (Only If Questionable)
___Expense Verification
___Residency Verification (Unless Categorically Eligible)
___Child Care Expense Verification
___Income Verification (Unless Categorically Eligible)
___Asset Verification (Unless Categorically Eligible)
IV-3: Actions to Be Taken:
___Check Interface Screen Before Terminating Interview
___Discuss FSET Requirements and Sanctions
___Discuss Requirements That Changes Be Reported, Including Simplified Reporting If Applicable
V. TAKING AND PROCESSING A MEDICAID APPLICATION USING GENERIC APPLICATION
V-1: Forms that must be completed or given to applicant:
___Generic Application/DC Healthy Families Application
___1288A Notice to Child Support Office (If Applicable)
___856/854 Medical Report/Social Information (If Applicable)
___Notice of Privacy Practices (If Applicable)
___1400 Notice to Applicants
___Third Party Liability Form (If Applicable)
___1052 Record of Case Action
___Checklist to Be Given to Applicant/recipient
___Voter Registration (If Applicable)
___Presumptive Eligibility Form(s) (If Applicable)
V-2: Information to Collect from Applicant:
___Residency Verification
___Income Verification
___Asset Verification
___Relationship Verification (If Applicable)
___Age Verification (If Needed)
___Confirmation of Pregnancy (If Applicable)
___Confirmation of Disability from SSA (If Applicable)
V-3: Actions to Be Taken:
___Explain EPSDT (If Applicable)
___Check Interface Screen Before Terminating Interview
___Discuss Child Support Requirement and Sanction (If Applicable)
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