Appendix A: Retention Periods for Specific Documents

The following documents should be retained either in the original paper form in the case record or as an electronically scanned document for a period of six (6) years from the date of its creation or the date it was last in effect, whichever is later.

All PA 600 series forms Application for benefits (PA 600, PA 600-S, PA 600R, PA 600AAB etc.)
PA/CS 173	WP Support and Good Cause Notice
PA/CS 173	GC Good Cause Determination
FAIR 293	Child Support Action Notice
PA/CS 611	Acknowledgement of Paternity
PA/CS 643A	Certification of Cooperation
PA 564	Semiannual Reporting Form
PA 564A	Late/Incomplete Notice
PA 586	Report of Physical/Mental Examination
PA 162	series Manual notices (see information related to sanctions below)
PA/FS 163	Notice of Denial of Expedited Services
HS 764	Authorization/Instruction Sheet (Retain for benefit issuance and controlled documents authorization only)
PW 764.1	Individual Add-On
HS 1815	Authorization for Use or Disclosure of Personal Information
PA 635	Medical Assessment Form
PA 1663	Employability Assessment Form
PA 1664	Employability Reassessment Form
PA 1671	Health Sustaining Medication Form
PA 1672	Drug and Alcohol Treatment Information Form
PA 731	Disability Advocacy Program Referral
PA 772	E&T Program Rights & Responsibilities
PA 78	Request for Employment Information
MA 112	Newborn Eligibility Form
I-94’s	Alien/Refugee documentation
PA 189	Overpayment Referral Data Input Form
FAIR 581	Food Stamp Program Disqualification
PA 1564	Referral to the Social Security Administration
PA 1661	Agreement of Mutual Responsibility (see information related to sanctions below)
PA 1665	Criminal History Inquiry
PA 1591	Child Care Provider Information Sheet
PA 1583	Verification of Child Care Costs
PA 1695	Immunization Certification
PA 1699	Child-Care Worksheet
PA 1701	Post-24 Month Compliance Review
PA 1714	TANF Benefits Received Outside of PA
PA 1727	Verification for Time-Out Based on Domestic Violence
PA 1747	Domestic Violence Verification Form
PA 207	Request for Investigation of Check
PA 239SP	Food Stamp Change Report Form
PA 1572	LTL Resource Assessment
PA 1809	Citizenship and Identity Information
PA 1817	Affidavit Attesting to Unavailability of Documentary Evidence or Citizenship
PA 1819	Affidavit Attesting to Identity of Minor Child 2
PA 176NR	Agreement to Dispose of Non-Resident Real Property
HS 176KM	Agreement and Authorization to Pay Medical Claim
FIRM 176K	Agreement and Authorization to Pay Claim
OIG 173	Reimbursement Referral
OIG-176	SSIAuthorization for Reimbursement of Assistance

All HIPAA client documents and our responses to HIPAA inquiries, complaints, HIPAA disclosures that are subject to HIPAA disclosure tracking requirements, requests for restrictions and our responses to those requests, requests for amendment, lists of records clients may access.

All information related to a sanction must be maintained in the record indefinitely. This documentation includes:

All PA/FS 162A and attachments related to the sanction.
All AMRs (PA 1661 and PA 1661W) related to the sanction.
PA 1706 – Compliance review appointment notice.
PA 1712 and partial redetermination letter which is sent when a sanction is ending.

Any verification or corroborating Good Cause (GC) evidence the client may have provided or was in the record and used to determine GC by the caseworker.

The following documents only need to be retained in the case record until the next completed renewal and/or update.

PA 4 Authorization for Release of Information
PA 10-SFSP Notice of Expiration of Certification

Some documents only need to be retained in the case record until the information is updated in the eCIS. Some examples:

PA 601N Case Narrative
PA 84 V Request for Verification of Birth

Reissued November 8, 2016 , replacing August 10, 2016, updated February 23, 2017