Dss 8194 Form PDF Details

Dss 8194 Form is an important document for any individual who is receiving or has received public assistance. The form is used to provide information about the person's eligibility and to certify that they are meeting all requirements of the program they are participating in. The form must be completed and submitted on a regular basis, and it can be used to track benefits payments and other important information. Anyone who needs help completing or understanding this form can get assistance from their local DSS office.

QuestionAnswer
Form NameDss 8194 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnc dss 8194, FNS, DSS-8194, dss 8194

Form Preview Example

TO:

FROM:

Work First

MA

FNS

Child Support

Program Integrity

DATE:

Services

Child Care

 

 

INCOME MAINTENANCE TRANSMITTAL FORM

I.

GENERAL INFORMATION

 

 

 

County Case No.

 

 

 

EIS/FSIS Case ID

IV-D Case No.

 

 

 

SIS ID No

Payee/Case Name:

________________________________

Telephone No:

Address:

 

 

 

 

 

Change of Address:

No

Yes -

mailing

residence

 

Family Unit Members

 

 

Non-Family Unit Members

Absent Parent Name:

 

 

 

ID No.

 

Absent Parent Name:

 

 

 

ID No.

 

Third Party Insurance:

Yes

No If yes, complete the following:

Name of Company:

 

 

Policy Number:

 

Person Covered:

_______________________________________________________________________________________

II.BENEFIT INFORMATION

FNS

MA

Work First – Payment type 1

 

Payment type 2

BENEFITS HAVE BEEN:

Reviewed

Revised

Approved

Denied/Term.

 

Payment type 1 transferred to payment type S

Payment type 2 transferred to payment type S

 

MA Case Pending Deductible

MA Case No Deductible

Date: ________________ Benefit Amt. _____________ Certified from _______________________to_______________________

Benefit Amt. from $__________to $___________ 1st Mo. Benefit $_________ Authorized from____________ to _____________

Eff. Date ________________ Approx. Date Rec’d ________________ Deductible $ ___________ Ongoing Benefit $__________

Denied/Term. Effective Date _________________________________________________________________________________

Reason for change:

 

 

 

 

 

 

 

 

 

 

 

Review Period:

 

From

 

 

 

 

To

 

 

CHILD CARE:

 

Type of Child Care Payment:

Direct

 

Vendor

 

 

 

Eff. Date:_________________________

Actual Costs $________________

Amt. Paid $________________

WORK FIRST PENALTY/SANCTION:

 

 

 

 

 

 

Reason for WORK FIRST penalty/sanction - noncompliance with:

MRA

Child Support

Substance Abuse Treatment

MRA noncompliance reason:

 

 

 

 

 

 

 

Other reason

 

 

 

 

 

 

 

III.INCOME VERIFICATION (EARNED AND UNEARNED)

Name:

 

 

 

 

Name:

 

 

 

Employer/Source:

 

 

 

 

Employer/Source:

 

 

 

Amt:

$

Date Rec’d:

Amt:

$

Date Rec’d:

Frequency:

 

 

 

 

 

Frequency:

 

 

 

 

Start Date: ________________ Term. Date: ________________

Start Date: _______________ Term. Date: _________________

IV.

OTHER

 

 

 

 

 

Service Requests:

 

 

 

 

 

Assistance with scheduling appointment

Date Requested

 

 

Assistance with transportation

Date Requested

 

 

Health Check for:

 

Date Requested

 

 

Family Planning requested for:

 

 

 

 

 

 

Other:

 

 

for:

 

Other reported Change/Information: (Such as change in household composition, reserve, good cause claim, change in absent parent information, etc.)_____________________________________________________________________________________

________________________________________________________________________________________________________

DSS-8194 (Rev 02/11)

Economic and Family Services

How to Edit Dss 8194 Form Online for Free

You are able to prepare MRA effectively with our PDFinity® PDF editor. The editor is continually maintained by our staff, receiving powerful functions and turning out to be a lot more convenient. To get the process started, go through these simple steps:

Step 1: Press the "Get Form" button above on this page to open our tool.

Step 2: Using our handy PDF tool, it is possible to accomplish more than merely fill in blanks. Try each of the functions and make your forms appear faultless with custom text added, or modify the file's original content to perfection - all that comes with the capability to incorporate any kind of images and sign the document off.

This PDF form will require particular data to be entered, so you must take whatever time to enter what's required:

1. While completing the MRA, be certain to complete all of the needed blank fields in its relevant part. This will help hasten the work, allowing your information to be processed fast and accurately.

Tips to fill in TRANSMITTAL part 1

2. Soon after the prior part is filled out, proceed to enter the applicable information in these: Payment type transferred to, MA Case No Deductible, Payment type transferred to, Date Benefit Amt Certified from, Reason for change Review Period C, From Type of Child Care Payment, Direct, Vendor, Actual Costs Amt Paid, WORK FIRST PENALTYSANCTION, Reason for WORK FIRST, Substance Abuse Treatment, MRA noncompliance reason, Other reason, and INCOME VERIFICATION EARNED AND.

Part # 2 of completing TRANSMITTAL

Concerning Direct and Vendor, make sure that you double-check them in this current part. Both of these could be the most significant ones in this file.

3. This next part is all about Service Requests Assistance with, Assistance with transportation, Health Check for, Family Planning requested for, Other, Date Requested, Date Requested, Date Requested, for, Other reported ChangeInformation, and DSS Rev Economic and Family - type in each of these blank fields.

A way to complete TRANSMITTAL part 3

Step 3: Soon after rereading the form fields, hit "Done" and you're done and dusted! Sign up with FormsPal now and instantly obtain MRA, all set for downloading. All alterations you make are preserved , making it possible to modify the file later as needed. FormsPal guarantees your information confidentiality by using a secure method that in no way saves or distributes any type of sensitive information typed in. Be confident knowing your docs are kept confidential whenever you use our editor!

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