An individual who requests a good cause waiver of a TANF or GA program requirement based on domestic violence shall complete the Domestic Violence Verification Form (PA 1747) provided by the CAO. The CAO will provide the verification form in person or by mail to an individual who requests the form and will instruct the individual to provide verification that may include one of the following: 55 Pa. Code § 108.10
Any type of documentation listed on the PA 1747, under Section 2, including law enforcement records, court records, medical/treatment records, social service records, child protective service records; or
Third party verification of the domestic violence from any of the entities or individuals listed in Section 3 of the form with knowledge of the circumstances which provide the basis for the waiver, including:
A domestic violence service provider;
A medical, psychological, or social service provider;
A law enforcement professional;
A legal representative; or
An acquaintance, friend, relative, or neighbor of the claimant, or other individual; or
If the individual is unable to safely obtain any of the items of evidence described in Sections 2 or 3 of the form, the client may self-affirm under Section 4 of the form that the individual cannot safely comply with a TANF/GA program requirement(s) due to domestic violence.
Documentation or third-party verification should be obtained, if possible, but self-affirmation will suffice to establish eligibility for a good cause waiver based upon domestic violence.
One verification form will suffice for one or more waivers.
The CAO may not, under any circumstance, have an individual who claims good cause based on domestic violence to do the following:
Contact the alleged abuser; or
Require the individual to obtain a Protection from Abuse Order.
Such contact could endanger the safety of a victim, the family or household.
A good cause waiver determination based on domestic violence will be made within 15 calendar days from the date the claim was initiated by the applicant or recipient. 55 Pa. Code § 108.11
The CAO will provide written notice of its determination of the waiver request to the applicant/recipient. The CAO will follow the notice requirements in Cash Assistance Handbook Chapters 104, Application, and 177, Notices. No denial notice shall be issued without prior review by both the CAO supervisor and manager. The notice to the applicant/recipient shall include the following information: 55 Pa. Code § 108.12
The basis for the determination and the right to appeal in writing on a PA 162 notice.
If good cause is established, the notice will:
State what requirement(s) are waived;
Explain the duration of the waiver;
Explain that a waiver will remain in effect as long as necessary, subject to review every six months.
If the good cause claim is denied, the notice will include:
What requirement(s) is not being waived;
The basis for the determination;
The legal authority for the denial;
The right to appeal and request a fair hearing;
What additional evidence or information is needed to substantiate the good cause claim and the timeframes in which the information must be provided;
An explanation that the individual must comply with the program requirement for which the waiver was requested.
If the good cause claim is denied;
Provide a copy of the PA 1747 form and explain the different ways in which it can be completed.
As soon as the determination is made on a good cause waiver of child or spousal support requirements, the CAO will send a copy of the PA 1747 establishing entitlement to the waiver to the Bureau of Child Support Enforcement Area Office. The PA 1747 must be accurately completed and must include the county code with the case number.
Waiver of a TANF program requirement is granted for as long as necessary, subject to review every six months. The review may be face-to-face or by telephone. 55 Pa. Code § 108.13
An individual who verified domestic violence with a document listed under Section 2 of the PA 1747, or a third party statement under Section 3 of the PA 1747 need not provide new or additional verification upon review at the six-month review if circumstances have not changed since the waiver was initially approved or since the last six month review. 55 Pa. Code § 108.13(1)
Example: In June, an individual provided copies of police records indicating domestic violence. A waiver was granted and a referral was made to the local domestic violence agency. The following January, at the six-month review, the individual’s circumstances have not changed, and the individual wants the waiver to continue. The waiver continues for an additional six months because the need for a waiver continues. No additional verification is required.
An individual who provided written self-affirmation of domestic violence under Section 4 of the form and requests that the waiver(s) continue, may do so by providing documentary verification as listed under Section 2 of the PA 1747, or by providing a third party statement under Section 3 of the PA 1747.
An individual who remains unable to provide verification under section 2 or 3 of the form in addition to the written affirmation, and who wishes to have the waiver(s) continue for an additional 6 months, may do so by again providing written affirmation of domestic violence under Section 4 of the form. Good cause continues on this basis.
Example: In June, an individual completed Section 4 and self-affirmed domestic violence and the need for a waiver. A waiver was granted. The following January, at the six-month review, the individual requested that the waiver continue and informed the CAO of continuing inability to provide verification listed in Sections 2 or 3. The individual re-affirms in Section 4 that domestic violence is an issue. The waiver continues on this basis.
NOTE: Individuals who are having difficulty obtaining verification in addition to their self-affirmation should be referred to domestic violence agencies or legal services for assistance in obtaining a third party statement.
An individual who, after 12 months, remains unable to provide verification under Sections 2 or 3 of the form and who wishes to have the waiver(s) continue may do so by providing written self-affirmation of domestic violence under Section 4 of the form, subject to approval by the Area Manager in consultation with the Bureau of Policy on a case-by-case basis. The individual’s waiver and benefits will continue pending the approval process. If a continued waiver is approved, the individual may, if necessary, continue to self-affirm at each subsequent six-month redetermination.
Example: An individual received a domestic violence waiver from January to June based on self-affirmation. The waiver was extended six more months, to the following January based upon a second self-affirmation. At the January review (12 months following the initial granting of the wavier), the individual states that circumstances have not changed and she wants the waiver to continue. The individual is still not able to provide any verification listed in Sections 2 or 3. The client completes Section 4 of the PA 1747 and the case is referred to the Area Manager for a waiver determination to be completed in coordination with the Bureau of Policy. The Area Manager reviews the circumstances and approves or denies the continuation of the waiver. The Area Manager does not have to review the case record again if circumstances do not change.
Reissued September 18, 2012, replacing January 31, 2012