The following forms are available to CAOs :
PA 4, Authorization for Release of Information.
Gives written consent of the individual for CAO contact with a third party.
PA 76, Request for Financial Information.
Asks for information about accounts held by a bank or other financial institution.
PA 78, Request for Employment Information.
Used to confirm current or previous employment, dates of employment, earnings, payroll deductions, medical coverage, Social Security number used for employment, company address, reasons for leaving employment, and other employment information.
PA 79, Request for Legal Information.
Asks for a search of courthouse records for information about real estate, inheritances, marriage, divorce, support actions, prosecutions, and other legal matters. The form is sent to the CAO in the county where the information is kept. That CAO will choose a staff individual to get the information, complete the PA 79, and return it to the CAO that sent it. Courthouse staff should not be asked to search or copy information requested by the CAO.
PA 83-Z, Request for Insurance Data.
Sent to an insurance company or local insurance agency to confirm there is a policy, the names of the policy owner and beneficiary, the policy’s cash value, and other information.
PA 112, Receipt for Payment of Child Care
May be filled out and signed by a child care provider to confirm the need for an income deduction or special-items allowances for child care.
Used to ask the individual for proof about income or resources found through the IEVS match.
PA 586, Report of Physical/Mental Examination.
Filled out by a doctor or licensed psychologist to confirm a disability when determining a TANF-related category or a disabled category. It is normally used when the doctor or psychologist does not have current information about the health of the individual.
PA 635, Medical Assessment Form.
Filled out by a doctor or licensed psychologist to confirm a disability for a TANF-related category or a disabled category.
Confirms the status of an application for SSI or RSDI referred to the Social Security Administration by the CAO Disability Advocacy Program.
NOTE: The CAO will attach the current IEVS printout to the PA 771 to show that the information is not on IEVS. The CAO will include a self-addressed stamped envelope.
SSA 1610, Public Assistance Agency Information Request.
Used to ask about the status of an application for OASDI or SSI or the amount of the benefit. The CAO will send the form to the local Social Security Administration office for information not available through the IEVS BENDEX, SDX, or Buy-In matches.
PA 1663, Employability Assessment Form.
Filled out by a doctor, psychologist, certified registered nurse practitioner, or physician’s assistant to confirm disability under the GA and GA-related MA programs. It tells whether the individual cannot work because of the disability.
PA 1664, Employability Reassessment Form.
Filled out by a doctor, psychologist, certified registered nurse practitioner, or physician’s assistant to reconfirm disability under the GA and GA-related MA (PD) programs. It tells whether the individual cannot work because of the disability.
PA 1671, Health-Sustaining Medication Assessment Form.
Filled out by a doctor, psychologist, certified registered nurse practitioner, or physician’s assistant to confirm an individual’s need for prescription drugs. This form is used with the PA 1663 and PA 1664 forms.
No form, Commonwealth of Puerto Rico, Department of Social Services Hotline.
Provides information about individuals who used to receive benefits in Puerto Rico.
Hotline information:
ADSEF – Central Office
Contact individual: Maritza Natal
Telephone Number: 787-289-7600 Ext. 2610
Fax Number: 787-289-7614
MNatal@adsef.gobierno.pr
Written requests:
ADSEF
Community Relations
P.O. Box 8000
San Juan, Puerto Rico 00910-0800
No form, VA Pension and Aid and Attendance Benefit Information.
If the recipient of a VA benefit receives an amount other than the current standard rate, the Veterans Administration will confirm the amount. The CAO will provide the VA with specific information about the individual. (See Appendix B for current VA rates, VA addresses, and information needed by the VA.)
The CAO may create its own forms for contacting local sources of verification. Any forms created 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.
Updated June 10, 2019, Replacing February 14, 2012