Fillable Appointment Notice And Verification Checklist (Page 2 of 2) in pdf

VERIFICATION CHECKLIST

IF YOU DO NOT UNDERSTAND ANY OF THE ITEMS LISTED BELOW OR WANT TO KNOW WHY THE INFORMATION OR

PROOF IS NEEDED, WE WILL EXPLAIN IT TO YOU AT THE INTERVIEW.

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Personal identification such as: driver’s license, Social Security card, military

Information concerning medical insurance coverage of children

discharge papers, or document showing your signature, photograph, or

for whom you are applying which is carried by the child’s absent

description. Acceptable for food stamps: A signed statement from someone

parent.

who knows you and can tell us, in person or over the phone, who you are.

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Proof of pregnancy. We require a written statement from your

doctor, clinic, or other medical source showing the expected

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delivery date.

Proof of your mailing address, if you have one, such as, rent or mortgage

receipt, utility bill, driver’s license, or other paper that shows where you live.

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If you have no papers with your address readily available, you can give us the

Registration cards for every motor vehicle owned by household

name of a person who can tell us, in person or over the phone, where you

members (car, truck, camper, boat, motorcycle, snowmobile)

live.

along with payment books or other documents showing balance

owed, if any, and the value of the vehicles.

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If you do not have a home or a fixed mailing address, please give us an

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address where you can receive mail, and the name of a person who knows

Car Insurance Information.

you and can tell us, in person or over the phone, that you live in Pennsylvania

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and are not in the state solely for vacation purposes.

Proof of application for benefits as follows:

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SSI

Sick Benefits/Disability

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Social Security number for every household member who has one, or proof

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Social Security

Veterans’ Benefits

of application for a Social Security number.

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Workers’ Compensation

Unemployment Compensation

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Birth verification for

__________________________________________.

Other __________________________________________

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Medicare Cards (Part A and Part B)

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Proof of resources you own or own jointly such as:

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Savings or checking accounts, Christmas or Vacation Club

If anyone in the household is a veteran, or is now in the military service, bring

Accounts (Current Bank Statement and Passbooks).

any papers that show serial number, or Social Security number, date of enlist-

ment and discharge, veteran’s claim number, pension, disability compensa-

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Hospitalization, health or accident insurance policies

tion awards, or allotments.

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Federal or State Income Tax Refunds

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Cash on Hand

Life Insurance Policies

Proof such as current school documents or correspondence which shows that

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your children age 16 or older attend elementary or secondary school or an

Burial Funds

Burial Plots

equivalent level vocational or technical school.

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Stocks or Bonds

IRAs

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Credit Union accounts

Certificates

Marriage License

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Trust Funds

Mutual Funds

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Proof of disability of any household member.

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Other __________________________________________

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This must be on a form provided by the Department.

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Proof of earned income and work expenses of household

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Release Papers from any Penal or Corrections institution including the name

members such as:

and phone number of the corrections officer.

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Name, address, and telephone number of employer for

anyone who is employed.

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Bills or receipts for medical services received in the past 4 months including

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Pay stubs for the last 30 days.

cost of medical insurance, dental care, and prescriptions.

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Pay stubs for the last 4 months.

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Proof of expense for child care (babysitter) or for care of

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The amount of support you are paying to your spouse or dependents who are

a disabled adult.

residing in or out of your home.

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Transportation expenses for employment.

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Name, address and telephone number of former employer.

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Proof of shelter and utility costs, such as lease, rent receipt, mortgage

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Written statement from last employer verifying last day of

payment book, tax receipts, home insurance, telephone, electric, fuel oil, coal,

work, date of last pay, and reason for termination.

gas, water, sewage, garbage, and utility installation bills or receipts.

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Proof of income from:

Other ______________________________________________________

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Training allowances

Rent or board

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Citizenship papers or alien/refugee registration cards for any persons in the

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Dividends

Tips

household who were not born in the United States.

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Interest

Odd Jobs

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Name, address and proof of the income and resources of your sponsor if you

Alimony or support

Other ____________________

are a sponsored alien.

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Latest income tax form or other reliable proof of income from self-

Names and addresses of certain relatives not living with you: your husband

employment and costs of producing self-employment.

or wife, or parent of any child for whom you want assistance. Bring their

Social Security numbers, and if these relatives are working, bring the names

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Proof of other income such as award letters of notices for:

and addresses of the people or companies for whom they work.

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Social Security

Pensions

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Divorce papers or other proof that your spouse or the parent of any child for

Union Benefits

Veterans’ Benefits

whom you are applying is absent from your home (such as a written state-

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Unemployment Comp.

Workers’ Compensation

ment from a non-related third party.)

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Black Lung Benefits

Sick Benefits

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Allotments

Railroad Retirement

We will want to know how much money or other help you get from relatives.

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Educational loans, grants, scholarships, and work study; and

If there are any court orders for support from relatives, bring your court order

card or number.

related expenses including tuition.

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Printout from the court to verify monthly payments.

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Other ____________________________________________

PA 253 11/07

Appointment Notice And Verification Checklist Page 2

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