Form 08Ad092E – Fill Out and Use This PDF

*ADM92 *

OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Date:

Case name:

Case number:

County number:

Supervisor/worker number: /

Client Contact and Information Request

My name is							. If you need to contact me, my days
in the office and my telephone number are shown below.
It is necessary for you to:
be interviewed
in our office			in your home			by telephone regarding					.
contact your worker											.
complete, sign, and return attached Form									.

provide PROOF of item(s) checked on the back of this form.

contact your worker to establish good cause for failure or refusal to participate in Temporary Assistance for Needy Families (TANF) Work activities.

Because you needed expedited			food benefits and/or						child care benefits, we
postponed asking you to give us certain information. You must now provide proof
of the information checked on the back of this page.
If the action checked above is not met before							your			will	be
	, effective			. If		you applied for			child care benefits,		the

earliest date you will be approved is the date you provide all requested verification and you have been interviewed.

If you disagree with a decision affecting your case, you have the right to request a fair hearing at the local OKDHS office within 30 days, or 90 days for food benefits, from the date of the notice you will receive advising you of the action.

If you do not want to receive benefits, please give a reason below, sign, date, and return to the local OKDHS office.

I wish to withdraw my application or discontinue my benefits because:

Your signature

Date

Form 08AD092E (ADM-92) revised 11-1-2010 may continue on next page, page 1 of 2

Name:			Case number:
Provide proof of items checked.
Earned income for the months of		. Provide pay stubs that include date, name

or Social Security number, and total income before deductions. If pay stubs are not available, provide a signed statement from your employer showing the dates and amounts paid, hourly rate, and hours worked. It must include any tips, bonuses, vacation or sick pay, and uniform allowance. It must be signed, dated, and include the address and phone number of the business.

Self-employment. Provide a copy of last year's tax return. If not available, provide current record books of earnings and business expenses.

Unearned income. Proof of income for the months of . Examples of unearned

income include, but are not limited to, Social Security; veterans, unemployment, or retirement benefits; pensions; child support; worker's compensation; and contributions. Provide award letter, letter from person or agency that provides the income, copy of check, or court order.

Citizenship or alien status. If citizen, provide birth certificate, United States passport, Certificate of Naturalization, Medicare card, or tribal membership card. If non- citizen, provide alien registration card or other document that shows legal status.

Identity. Provide driver's license, work/school/benefit ID card, birth certificate, voter registration card, or pay stub showing name.

Social Security and/or Medicare card. You may provide the Social Security number instead of the Social Security card.

Resources or assets. Provide copies of bank statements, life or burial insurance policies, property deed and/or mineral rights, title to vehicle and amount owed, stocks, bonds, certificates of deposit (CD), individual retirement accounts (IRA), trust funds, or other documents. If you own land or a house you are not living in, provide proof of the equity amount you have in the property.

Accident or health insurance. Provide a copy of insurance card or policy that includes the name of the company, policy number, and who is insured.

Persons living in your home. Proof may be statements from other persons or the names and phone numbers of persons to contact.

Utility bill for LIHEAP. Provide a recent bill showing the name on the account, the account number, and utility supplier. If you have a cut off notice, provide the notice.

Medical expenses. Provide proof such as monthly health insurance premiums, prescription costs, medical supplies, and payments to medical providers.

Need for child care. Provide work, training, or school schedule showing the days of the week and the hours of the day you attend. If hours vary, you may provide a signed and dated statement with contact number from the employer or instructor explaining your schedule.

Other.

Please send copies. Originals cannot be returned.

Form 08AD092E (ADM-92) revised 11-1-2010 may continue on next page, page 2 of 2