Form Dss-8194 - Income Maintenance Transmittal Form
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1TO:
Work First
MA
FNS
Child Support
Program Integrity
Services
Child Care
FROM:
DATE:
INCOME MAINTENANCE TRANSMITTAL FORM
I .
GENERAL INFORMATION
County Case No.
EIS/FSIS Case ID
IV-D Case No.
SIS ID No
________________________________
Telephone No:
Payee/Case Name:
Address:
Change of Address:
No
Yes -
mailing
residence
Family Unit Members
Non-Family Unit Members
Absent Parent Name:
ID No.
Absent Parent Name:
ID No.
Third Party Insurance:
Yes
No If yes, complete the following:
Name of Company:
Policy Number:
Person Covered:
_______________________________________________________________________________________
II.
BENEFIT INFORMATION
FNS
MA
Work First – Payment type 1
Payment type 2
BENEFITS HAVE BEEN:
Reviewed
Revised
Approved
Denied/Term.
Payment type 1 transferred to payment type S
Payment type 2 transferred to payment type S
MA Case Pending Deductible
MA Case No Deductible
Date: ________________ Benefit Amt. _____________ Certified from _______________________to_______________________
st
Benefit Amt. from $__________to $___________ 1
Mo. Benefit $_________ Authorized from____________ to _____________
Eff. Date ________________ Approx. Date Rec’d ________________ Deductible $ ___________ Ongoing Benefit $__________
Denied/Term. Effective Date _________________________________________________________________________________
Reason for change:
Review Period:
From
To
C HILD CARE:
Type of Child Care Payment:
Direct
Vendor
Eff. Date:_________________________
Actual Costs $________________ Amt. Paid $________________
WORK FIRST PENALTY/SANCTION:
Reason for WORK FIRST penalty/sanction - noncompliance with:
MRA
Child Support
Substance Abuse Treatment
MRA noncompliance reason:
Other reason
III.
INCOME VERIFICATION (EARNED AND UNEARNED)
Name:
Name:
Employer/Source:
Employer/Source:
Amt:
$
Date Rec’d:
Amt:
$
Date Rec’d:
Frequency:
Frequency:
Start Date: ________________ Term. Date: ________________
Start Date: _______________ Term. Date: _________________
IV.
OTHER
Service Requests:
Assistance with scheduling appointment
Date Requested
Assistance with transportation
Date Requested
Health Check for:
Date Requested
Family Planning requested for:
Other:
for:
Other reported Change/Information: (Such as change in household composition, reserve, good cause claim, change in absent
parent information, etc.)_____________________________________________________________________________________
________________________________________________________________________________________________________
DSS-8194 (Rev 02/11)
Economic and Family Services
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