Appendix F Forms

Georgia State Seal

Georgia Division of Family and Children Services
TANF Policy Manual

Policy Title:

Forms Table of Contents

Effective Date:

May 2024

Chapter:

Appendix F

Policy Number:

Appendix F

Previous Policy Number(s):

MT 76

Updated or Reviewed in MT:

MT-77

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

osah.ga.gov

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 TANF, Food Stamps and Medical Assistance For voter registration information, refer to * on page 1.

07/23

State Office/PAMMS

297 LP

Application for TANF, Food Stamps or Medical Assistance (Large Print)

07/23

State Office/PAMMS

297 SP

Application for TANF, Food Stamps or Medical Assistance (Spanish) For voter registration information, refer to * on page 1.

07/23

State Office/PAMMS

297 SP LP

Application for TANF, Food Stamps or Medical Assistance (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

Food Stamps, Medicaid, TANF Renewal Form For voter registration information, refer to * on page 1.

07/23

State Office/PAMMS

508 LP

Food Stamps, 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

Food Stamps, 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