Fillable Appointment Notice And Verification Checklist printable pdf download

RESET FIELDS

C A O A D D R E S S H E R E

APPOINTMENT NOTICE

AND

VERIFICATION CHECKLIST

IN ORDER TO DETERMINE YOUR ELIGIBILITY FOR

YOUR SCHEDULED INTERVIEW IS FOR

CASH

MEDICAL

FOOD

DAY-DATE

TIME

I I

A.M.

ASSISTANCE

STAMPS

P.M.

PLACE

AN INTERVIEW HAS BEEN SCHEDULED AT THE TIME AND

PLACE SHOWN.

READ THIS ENTIRE FORM CAREFULLY

PLEASE BE ON TIME:

IF YOU ARE UNABLE TO COME TO THE OFFICE OR CANNOT KEEP THIS APPOINTMENT, PLEASE LET US KNOW AS SOON AS POSSIBLE. YOU

MAY ASK FOR ANOTHER APPOINTMENT AND WE WILL SCHEDULE ONE AS QUICKLY AS WE CAN.

YOU MUST PROVIDE AND PAY FOR YOUR OWN TRANSPORTATION WHEN ATTENDING SCREENING AND APPLICATION INTERVIEWS.

IF YOU ARE CURRENTLY RECEIVING BENEFITS, YOU MAY BE ENTITLED TO PAYMENT FOR TRANSPORTATION.

WHO SHOULD COME TO THE INTERVIEW:

CASH

Husband and wife, if living together, and all other persons age 18 or older need to be interviewed.

MEDICAL ASSISTANCE

If you are only applying for medical assistance, you, your spouse, or another person may apply on your behalf. Certain households may not be required

to have a face-to-face interview.

FOOD STAMPS

If you are only applying for food stamps, you, any responsible member of your household, or any other person authorized by you to make the application

on your behalf, need be present for the application interview. Certain households may be interviewed for food stamps by telephone. If attending an office

interview is a hardship, please discuss it with us.

WHAT INFORMATION WILL BE NEEDED AT THE INTERVIEW:

To help us decide whether you (or anyone else for whom you are applying) are eligible for the benefits you want, we will need information about you and

your household and proof of that information.

On the reverse side of this form is a “Verification Checklist.” If a box next to an item is checked, bring all of the papers and proof of the information

listed. If you are unable to bring in all of the information, we may still be able to authorize cash assistance or medical assistance if you can show us that

you cooperated in attempting to obtain the information requested. Also, the information you are able to provide may be sufficient to prove your eligibility for

food stamps, even if it is not sufficient to show that you are eligible for other benefits.

When proof on paper (receipts, pay stubs, and other documents) is not available, we may be able to help you provide proof of some items by contacting

persons outside of your household.

For reapplications, you are not required to bring proof of items for which you have already provided proof (EXAMPLES: age, Social Security Numbers,

permanent disability) unless we explain why it is necessary. You must cooperate in providing required proof, or cash assistance, medical assistance, or food

stamp benefits may be denied. If you are cooperating in the completion of your application or reapplication, we will help you provide proof, as needed.

NO PERSON WILL BE EXCLUDED FROM ANY PROGRAMS OF

THE PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BECAUSE

OF RACE, COLOR, SEX, RELIGIOUS CREED, POLITICAL BELIEFS,

NATIONAL ORIGIN, OR DISABILITY. SUCH DISCRIMINATION IS

PROHIBITED BY BOTH FEDERAL AND STATE LAWS.

SIGNATURE OF WORKER

DATE

TELEPHONE

I I

CLIENT

CASE RECORD

PA 253 11/07