The CAO may develop its own forms for contacting local sources of verification. Any forms developed for use outside the CAO must be approved by Central Office. The CAO will send a typed copy of the proposed form to the Area Manager for review and approval.
The following forms are available through Docushare, Print-on-Demand, Imprint or Supplier Relationship Management Requisition System (SRM):
INS G-845S Save Document Verification Report
Used for primary and secondary verification of the lawful immigration status of aliens. See Supplemental Handbook, Chapter 740.
PA 4 Authorization for Release of Information
Provides the written consent of the client for CAO contact with a third party.
PA 76 Request for Financial Information
Requests information concerning accounts held by a bank or other financial institution.
NOTE: When sending a request to the individual for bank account, or any other financial information, the IMCW should identify the bank name or financial entity by only the last four digits of the account number to assure the financial account information is protected.
Example: Commerce xxxxxx1234
PA 78 Request for Employment Earnings Information
Used for verification of current or previous employment, dates of employment, earnings, payroll deductions, medical coverage, SSN used for employment, address, reason for termination, etc. For Past Employ Verification Service Guidelines, see Appendix F.
PA 79 Request for Legal Information
Requests a search of courthouse records for information about real estate, inheritances, marriage, divorce, support actions, prosecutions, etc.
PA 83-Z Request for Insurance Data
Sent to an insurance company or local insurance agent to verify the existence and status of a policy, names of owner and beneficiary, cash value, etc.
PA 84-R Request for Information - Railroad Retirement Board
Used to verify Railroad Retirement benefit amount and Medicare status. Mail or fax to the US Railroad Retirement Board office serving the area in which the client resides:
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1514 11th Avenue
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Moorehead Federal Building |
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Federal Building., Room 576 P.O. Box 11697
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Siniawa Plaza II |
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Nix Federal Bldg, Suite 301. |
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PA 112 Receipt for Payment of Child Care
May be completed and signed by the provider of care to verify the need for an income deduction or special items allowances for child care.
Exception: The PA 1583 must be used for special allowances for supportive services by participants in RESET.
PA 162-VR IEVS Client Verification Request Letter
Used to request verification from the client for income or resources identified through the IEVS match.
PA 586 Report of Physical/Mental Examination
The form completed by a physician or psychologist to verify an incapacity for determining TANF category. Normally used when the physician or psychologist does not have current information about the health of the client.
PA 635 Medical Assessment Form
The form completed by a physician, psychologist, physician’s assistant, or nurse practitioner to verify an incapacity for determining TANF category. This form may also be used to determine employability status if it is completed by a physician or psychologist.
PA 731 DAP Referral Form
Verifies the status of an SSI/SSDI application that was referred to SSA by the CAO Disability Advocacy Program.
PA 1583 Verification of Child Care Costs
Used for verification of child care costs for special allowances for supportive services in ETP and for the Transitional Child Care Program.
PA 1663 Employability Assessment Form
The form completed by a physician or psychologist to verify disability and whether the disability precludes any gainful employment.
PA 1664 Employability Reassessment Form
The form completed by a physician or psychologist to reverify continued disability and whether the disability precludes any gainful employment.
PA 1671 Health-Sustaining Medication Assessment Form
The form completed by a physician to verify a client's need for health-sustaining medication. This form may be used alone or in conjunction with the PA 1663 and PA 1664 employability assessment forms.
PA 1672 Drug and Alcohol Treatment Information Form
The form completed by a physician, director, or professional case manager of or affiliated with a drug and alcohol treatment program. It is used to refer clients to the treatment program, to verify initial enrollment and satisfactory participation in the program and to verify employability status.
PA 1714 TANF Cash Benefits Received Outside of PA
A recipient meeting TANF requirements who previously received, but did not exhaust TANF cash benefits in another state, may receive TANF in Pennsylvania if otherwise eligible. The 60-month limit balance will be adjusted to reflect TANF cash benefits received in the other state on or after March 3, 1997. Receipt of TANF days in another state may be verified using a PA 1714 form. Refer to the State TANF Contact Numbers web page to determine where to send the PA 1714.
SSA 1610 Public Assistance Agency information Request
This form is used to request verification of the status of an application for OASDI, SSI or the amount of the benefit. Request is made to the local SSA office for information not available .through the IVES Bendex, SDX or Buy-In matches.
Provides information and verification on clients who had previously received benefits in Puerto Rico.
Puerto Rico Dept. of Social Economic Development for Families
Telephone Number: 1-787-289-7600, Extension 2638 or 2610
Fax: 1-787-289-1199
Gobierno de Puerto Rico
Administracion de Desarrollo Socioeconomico de la Familia (ADSEF)
PO Box 8000
San Juan, PR 00910-2498
If the recipient of a VA benefit is receiving an amount other than the current standard rate, the Veterans Administration will provide verification of the amount. The CAO must provide the VA with specific information about the client. See Appendix B for listings of the current VA rates, VA addresses, and information required by VA.
Reissued September 20, 2012; replacing January 31, 2012; reviewed October 7, 2013