Form Pa 1883 - Special Allowance, Spal, Verifi Cation
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1RESET FIELDS
County Assistance Offi ce, CAO, Use Only
Participant’s Name: ____________________________________
CO/Record#: ______________
Request Date: _____________
Special Allowance, SPAL, Verifi cation Form
SPALs requested to support participation in:
Employment
Education/Training/Activity
EDUCATION, TRAINING, OTHER ACTIVITIES – The CAO,
List employer name and address or E&T program/activity/site:
Employment & Training Contractor, E&T, school or training
provider may complete this form.
_____________________________________________________
EMPLOYMENT – The CAO or E&T Contractor may complete
_____________________________________________________
this form based on collateral contact with the employer or
other validation such as an employee handbook or statement
_____________________________________________________
from an employer that the item is required.
An employer should not be asked to complete this form.
This form is used to discuss the availability of existing supports and determine what supportive services are required to
enable participation in employment, education, training or an activity noted on the Agreement of Mutual Responsibility, AMR
or Employment Development Plan, EDP. Consideration is given to whether participation would not be possible without the
item or service requested; and whether the item or service is provided by the employer, activity, school or training provider.
Consideration should always be given for the least costly, most practical item or service to meet the need. Documentation
to support the SPAL request must be returned to the CAO within 10 days of the request.
THIS FORM AND SUPPORTING DOCUMENTS ARE DUE TO THE CAO BY_________________________
TYPE OF SPAL REQUESTED: __________________________ __________________________
___________________________
__________________________ __________________________
___________________________
Complete when transportation-related SPALs are requested:
– What form of transportation does this individual use to get to medical appointments, the grocery store or other places he or she
needs to go?
Own Transportation
Public Transportation/Bus
Walk
Neighbor/Friend
County Transportation Service
Other ____________________________
– Can this mode of transportation be used to get to this employment, activity, school or training site? YES _____ NO _____
If no, explain why not. _____________________________________________________________________________________
Complete when other types of SPALs are requested:
– Does the employer, activity, school or training site require the requested item(s) or service(s)? YES _____ NO _____
If yes, what specifi c items are required? ______________________________________________________________________
– Does this individual already have these items? YES _____ NO _____
– Does the employer, activity, school/training site or another personal or community source provide assistance for these item(s):
a) at no cost to the participant? YES _____ NO _____ If yes, for what time period? _______________
b) for a fee? YES _____ NO _____ If yes, at what cost? ________________________________________
NOTE: The E&T participant’s personal fi nancial resources are not considered.
PERSON COMPLETING THIS FORM ____________________________________ PHONE NUMBER __________________________
______________________________________________________
Employed by: CAO, E&T Program or Agency (circle one)
(print name)
CAO USE ONLY: If the individual is eligible for a SPAL:
•
Consider the least costly, most practical service or item based on all considerations.
•
Narrate the SPAL according to guidance in Cash Assistance Handbook, Chapter 135.64.
•
Ask the individual to provide a written estimate prior to authorization if the cost of the item or service is not already
known to the CAO.
•
Explain that a receipt must be provided to the CAO within 14 days to avoid an overpayment.
•
Send a Notice of Eligibility/Ineligibility to advise the individual about the eligibility determination for SPALS.
PA 1883 11/10
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