Application For Prc Assistance Page 2
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1
2This Section is for Agency Use Only: PRC Authorization/Denial Form
Name of Applicant ____________________________________________Case Number ______________________
Date of Application ___/___/___
30 Day Budget Period ______________ to _________________
PRC issued within previous 12 rolling months?
Yes
No
If yes, month, date & category: ____________________________________________________________________
Utility 3 month payment history:
Month
Amt Paid
Source
(If applicable)
__________
__________
__________
__________
__________
__________
__________
__________
__________
CSEA – SETS checked?
Yes
No
Fraud list?
Yes
No
If yes, detail: _____________________________________________________________________________________
Currently in receipt of benefits?
Yes
No
If yes, category and amount: _____________________________________________________________________
Currently on sanction?
Yes
No
If yes, date & occurrence: _________________________________________________________________________
Liquid Assets verified?
Yes
No
50% Co-Pay Received?
Yes
No
Amount $ ____________________
□ PRC Approved □ PRC Denied
□ Prevention □ Retention □ Contingency
1. Vendor’s Name:
Address
City
State
Zip
Phone
Account Number
Name on Account
Voucher Begin Date:
Voucher Ending Date:
Amount:
Reason for Denial:
Caseworker Signature
Date
Supervisor Signature
Date
G:\pvt\community_services\Forms\IntraNet Originals\prc-application.doc 01/13/10
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