Appendix F Forms | TANF
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Georgia Division of Family and Children Services |
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Policy Title: |
Forms Table of Contents |
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Effective Date: |
October 2024 |
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Chapter: |
Appendix F |
Policy Number: |
Appendix F |
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Previous Policy Number(s): |
MT 77 |
Updated or Reviewed in MT: |
MT-78 |
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TANF PROGRAM MANUAL
TABLE OF CONTENTS
Appendix F Forms
Voter Registration Information:
*For a copy of the Voter Registration Application Form and information on how to apply to register to vote, visit website: www.sos.ga.gov
Also, refer to Form #VRA-95.
| FORM# | NAME OF FORM | REVISION DATE | SOURCE/ORDER INFORMATION |
|---|---|---|---|
VRA-95 |
Voter Registration Application Form |
Secretary of State www.sos.ga.gov |
|
1 |
OSAH FORM 1 - TANF |
10/23 |
|
SS |
Application for a Social Security Card |
N/A |
www.ssa.gov |
102 |
Waiver of Timely Notice Period |
02/09 |
State Office/PAMMS |
104 |
Statement of Child Care Expense |
06/16 |
PAMMS |
104SP |
Declaraciónde costos de guardería |
06/16 |
PAMMS |
114 |
TANF Hardship Waiver Case Staffing Worksheet |
01/11 |
State Office/PAMMS |
118 |
Request for Hearing |
1/26/22 |
PAMMS |
121 |
Interim Review of Eligibility |
09/05 |
PAMMS |
126 |
Self-Employment Work Calendar |
06/16 |
PAMMS |
126SP |
Calendario De Trabajo Del Empleo Por Cuenta Propia |
06/16 |
PAMMS |
130 |
TANF and Family Medicaid Child Support Letter |
06/16 |
State Office/PAMMS |
130SP |
TANF y MedicaidFamiliar,Carta de ayuda infantil y médica |
06/16 |
State Office/PAMMS |
136 |
County Request for a Final Appeal |
02/10 |
PAMMS |
138 |
Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement and Third Party Resource Requirements |
06/16 |
State Office/PAMMS |
138 SP |
Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Enforcement and Third Party Resource Requirements |
06/16 |
State Office/PAMMS |
139 |
Contribution Statement |
06/16 |
State Office/PAMMS |
139 SP |
Declaracion Contributiva |
06/16 |
State Office/PAMMS |
173 |
Verification Check List |
06/10 |
State Office/PAMMS |
173 SP |
Lista de Verification |
11/09 |
State Office/PAMMS |
173A |
Appointment Letter |
06/16 |
State Office/PAMMS |
173A SP |
Carta De Cita |
06/16 |
State Office/PAMMS |
188 |
Social Data Report |
06/16 |
PAMMS |
188SP |
Informe de Datos Sociales |
06/16 |
PAMMS |
190 |
TANF Conciliation/Material Violation Staffing |
12/22 |
PAMMS |
190SP |
Conciliacion / Dotacion del Personal por incumplimiento sustancial de TANF |
12/22 |
PAMMS |
191 |
Disposition Notification TANF Hardship Waiver |
07/23 |
State Office/PAMMS |
191 SP |
Notificacion De Disposicion De Revocatoria De Dificultad De TANF |
07/23 |
State Office/PAMMS |
192 |
Disposition Notification TANF Lifetime Limit Termination or Denial |
07/23 |
State Office/PAMMS |
192 SP |
Terminacion Del Limite De Vida O Negativa De Dificultad De Asistencia Temporal Para Familias |
07/23 |
State Office/PAMMS |
193 |
TANF Prenatal Care Verification |
06/16 |
State Office/PAMMS |
193 SP |
Verificacion de Cuidado Prenatal de |
06/16 |
State Office/PAMMS |
194 |
TANF Assessment for Domestic Violence, Sexual Assault, Sexual Harassment, or Stalking |
08/22 |
State Office/PAMMS |
194 SP |
EVALUACIÓN SOBRE VIOLENCIA DOMÉSTICA, AGRESIÓN SEXUAL, ACOSO SEXUAL O ACOSO DEL PROGRAMA DE ASISTENCIA TEMPORAL PARA FAMILIAS EN NECESIDAD (TANF, en inglés) |
08/22 |
State Office/PAMMS |
195 |
TANF Community Service Agreement |
06/16 |
State Office/PAMMS |
196 |
TANF Family Service Plan-Personal Responsibility Plan |
09/20 |
State Office/PAMMS |
196 SP |
PLAN DE SERVICIO FAMILIAR DE TANF |
09/20 |
State Office/PAMMS |
196A |
TANF Family ServicePlan-WorkPlan |
09/20 |
State Office/PAMMS |
196A SP |
Plan De Servicio Familiar De Tanf Plan De Trabajo |
09/20 |
State Office /PAMMS |
197 |
TANF Sanction /Panel REVIEW GUIDE |
09/05 |
State Office/PAMMS |
197A |
Guide for TANF Sanction Home Visit |
09/05 |
PAMMS |
199 |
TANF ES Case Staffing Form |
02/19 |
PAMMS |
200 |
TANF Subsidized Employment Agreement |
09/07/2022 |
State Office/PAMMS |
205 |
Disposition Notification Employment Intervention Services |
03/21 |
State Office/PAMMS |
205 SP |
Notificacion Disposicion Servicios De intervencion EnEl Empleo |
03/21 |
State Office/PAMMS |
207 |
DispositionNotificationWork Support Payment |
07/23 |
State Office/PAMMS |
207 SP |
Notificacion De Disposicion Pagos De Apoyo Al Trabajo |
07/23 |
State Office/PAMMS |
239 |
TANF Budget Sheet |
10/18 |
PAMMS |
281 |
GRG Monthly Subsidy/ CRISP Payments |
11/16 |
State Office/PAMMS |
282 |
Disposition Notification Grandparents Raising Grandchildren (GRG) Crisis Intervention Services Payment (CRISP) |
04/26/21 |
State Office/PAMMS |
282 SP |
Notificacio’n de la Disposici’on de los abuelos a los nietos (GRG) Pago de los servicios de intervenc’ion de crisis (CRISP) |
04/26/21 |
State Office/PAMMS |
297 |
Application for Benefits, refer to * on page 1. |
07/23 |
State Office/PAMMS |
297 LP |
Application for Benefits (Large Print) |
07/23 |
State Office/PAMMS |
297 SP |
Application for Benefits (Spanish) For voter registration information, refer to * on page 1. |
07/23 |
State Office/PAMMS |
297 SP LP |
Application for Benefits (Spanish Large Print) |
07/23 |
State Office/PAMMS |
297A |
Rights and Responsibilities For voter registration information, refer to * on page 1. |
07/23 |
State Office/PAMMS |
297A LP |
Rights and Responsibilities (Large Print) |
07/23 |
State Office/PAMMS |
297A SP |
Rights and Responsibilities (Spanish) For voter registration information, refer to * on page 1. |
07/23 |
State Office/PAMMS |
297A SP LP |
Rights and Responsibilities (Spanish Large Print) |
07/23 |
State Office/PAMMS |
329 |
Disposition Notification –TANF First Sanction |
07/23 |
State Office/PAMMS |
329 SP |
Notificación De Sanciónde Tanf |
07/23 |
State Office/PAMMS |
351 |
Grg Msp/Crisp Work Sheet |
04/16 |
PAMMS |
354 |
Expense Statement |
08/20 |
State Office/PAMMS |
354 SP |
Declaracio’n De Gastos |
08/20 |
State Office/PAMMS |
373 |
SimplifiedReapplication Process |
02/15 |
PAMMS |
482 |
Work Experience Agreement |
06/16 |
State Office/PAMMS |
482 SP |
Contrato ParaObtener Experiencia DeTrabajo |
06/16 |
State Office/PAMMS |
486 |
Claims Repayment Agreement |
09/20 |
State Office/PAMMS |
486 SP |
Acuerdo De Reembolso Por Sobrepago |
04/04 |
State Office/PAMMS |
489 |
TANF Work Requirement Exemption |
06/16 |
State Office/PAMMS |
489 SP |
Formulario De Exención De Requisito De Trabajo De Tanf |
06/16 |
PAMMS |
490 |
TANF Family Assessment |
01/16 |
State Office/PAMMS |
490 SP |
Evaluación de Empleo de Servicios delSolicitante |
06/12 |
PAMMS |
491A |
TANF Work Readiness Assessment – ADA Addendum |
03/03 |
State Office/PAMMS |
491A SP |
EVALUACIÓN FAMILIAR DE SERVICIOS DE EMPLEO |
06/12 |
State Office/PAMMS |
495 |
Job Search Record |
08/22 |
State Office/PAMMS |
495 SP |
Historial De Busqueda De Trabajo |
08/22 |
State Office/PAMMS |
508 |
SNAP, Medicaid, TANF Renewal Form For voter registration information, refer to * on page 1. |
07/23 |
State Office/PAMMS |
508 LP |
SNAP, Medicaid, TANF Renewal Form |
07/23 |
State Office/PAMMS |
508 SP |
Formulariode Renovacion de Cupones De Alimentos Medicaidtanf. For voter registration information, refer to * on page 1. |
07/23 |
State Office/PAMMS |
508 SP LP |
SNAP, Medicaid, TANF Renewal Form (Spanish Large Print) |
07/23 |
State Office/PAMMS |
516 |
Record of Attendanceand Performance Report |
10/22 |
State Office/PAMMS |
516 SP |
Registro De Asistenciae Inform Dedemsempeno |
10/22 |
State Office/PAMMS |
517 |
Record of School Attendanceand Performance Report |
09/23 |
State Office/PAMMS |
517 SP |
Registro De Asistencia Escolar E Informe De |
09/23 |
State Office/PAMMS |
522 |
“What Every Person Needs to Know” (Domestic Violence) |
07/23 |
State Office |
522 SP |
“Lo Que Toda Persona Necesita Saber Folleto Sobre Violencia |
07/23 |
State Office |
523 |
Family Violence Option Assessment Report |
08/22 |
State Office/PAMMS |
524 |
TANF Community Outreach Services |
11/15 |
State Office |
524 SP |
Departamento de Recursos Humanos de Georgia |
11/15 |
State Office |
525 |
Authorization to release DV Indicator |
10/11 |
PAMMS |
713-CS |
OCSS/DFCS Communication Form |
09/20 |
State Office |
785 |
Family Planning Services Referral |
06/16 |
State Office/PAMMS |
785 SP |
Remisióna Los Servicios De Planificación Familiar |
06/16 |
State Office/PAMMS |
806 |
Medical Statement |
06/16 |
State Office/PAMMS |
806 SP |
DECLARACIÓN MÉDICA |
06/16 |
State Office/PAMMS |
809 |
Verification of Earned Income |
06/16 |
State Office/PAMMS |
809 SP |
Formulario de Verificación de Empleo |
06/16 |
State Office/PAMMS |
846 |
Change Report Form |
10/22 |
State Office/PAMMS |
846 SP |
Formulario para Modificar el Informe |
10/22 |
State Office/PAMMS |
1215 |
Federal Tax Information– Secured Verification Letter |
2012 |
PAMMS |
5459 |
Authorization for Release of Information |
07/16 |
State Office |
5459 SP |
Autorización Para Ceder Información |
07/16 |
State Office |
5460 |
Notice of Privacy Practices |
12/23 |
State Office/PAMMS |
5460 SP |
Notificación de prácticas de privacidad de HIPAA |
12/23 |
State Office/PAMMS |
5667 |
Request for Investigation |
10/18 |
Office of Investigative Services (OIS) |
5706 |
TANF/Family Medicaid Child Support Enforcement Compliance Agreement |
01/07 |
State Office/PAMMS |