Form 470 0615 – Fill Out and Use This PDF

Iowa Department of Human Services

APPLICATION FOR ALL SOCIAL SERVICES

including Title IV-A Emergency Assistance

Part A:

Applicant			Source of Income			Monthly Income
Street Address				City		State	Zip Code
Name (Children and Other Adults)		Relationship			Birth Date	Social Security Number
Signature of Applicant, Recipient or Legal Guardian						Date
DHS or JCO Worker Signature						Date Received

COMPLETE ONLY FOR TITLE IV-A EMERGENCY ASSISTANCE

Part B: (Check appropriate box.)

An applicant is eligible for IV-A Emergency Assistance services if all of the following criteria are met:

Yes No

An emergency exists because one of the following situations exists:

♦Abuse, neglect, or abandonment of children, or risk of same or;

♦Children in imminent danger where continued presence in the home is not in the best interests of the child or;

♦Children have been removed from the home or are at risk of removal from the home because of abuse, neglect, or inability of parents to provide needed care or treatment, or control the behavior of the child.

This emergency did not arise because of an applicant’s or applicant’s family’s refusal to accept employment or training within 30 days of the date of this application without good cause.

This application for emergency services was made on behalf of a child living with, or within the past six months having lived with, a specified relative in a place of residence maintained as the child’s own home.

The applicant family is receiving FIP, SSI, Food Assistance, or Medicaid benefits in the month of the application, or does not have cash to provide needed emergency care or services.

YOUR RIGHTS:

♦You have the right to identify your service needs and to apply for social services, the right to have your application acted upon within 30 days, the right to receive written notification of the action on your application, and the right to appeal if services are denied, terminated or reduced. If you wish to appeal, you may do so in writing at your county office. Receipt of a service depends on your eligibility for the service and also on our ability to provide that service.

♦You have the rights of confidentiality, protection and privacy.

♦You have the right to request family planning (birth control) as a service for yourself or a member of your family. Family planning is voluntary. No one can say that to get a service you must use birth control, or use a certain method of birth control.

470-0615 (Rev. 5/09)

You Have the Right to Appeal

What is an appeal?

An appeal is asking for a hearing because you do not like a decision the Department of Human Services (DHS) makes. You have the right to file an appeal if you disagree with a decision. You do not have to pay to file an appeal. [441 Iowa Administrative Code Chapter 7].

How do I appeal?

Filing an appeal is easy. You must appeal in writing by doing one of the following:

•Complete an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/, or

•Write a letter telling us why you think a decision is wrong, or

•Fill out an Appeal and Request for Hearing form. You can get this form at your county DHS office.

Send or take your appeal to the Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. If you need help filing an appeal, ask your county DHS office.

How long do I have to appeal?

You must file an appeal:

•Within 30 calendar days of the date of a decision or

•Before the date a decision goes into effect

If you file an appeal more than 30 but less than 90 calendar days from the date of a decision, you must tell us why your appeal is late. If you have a good reason for filing your appeal late, we will decide if you can get a hearing.

If you file an appeal 90 days after the date of a decision, we cannot give you a hearing.

Can I continue to get benefits when my appeal is pending?

You may keep your benefits until an appeal is final or through the end of your certification period if you file an appeal:

•Within 10 calendar days of the date of a decision or

•Before the date a decision goes into effect

Any benefits you get while your appeal is being decided may have to be paid back if the Department’s action is correct.

How will I know if I get a hearing?

You will get a hearing notice that tells you the date and time a telephone hearing is scheduled. You will get a letter telling you if you do not get a hearing. This letter will tell you why you did not get a hearing. It will also explain what you can do if you disagree with the decision to not give you a hearing.

Can I have someone else help me in the hearing?

You or someone else, such as a friend or relative can tell why you disagree with the Department’s decision. You may also have a lawyer help you, but the Department will not pay for one. Your county DHS office can give you information about legal services. The cost of legal services will be based on your income. You may also call Iowa Legal Aid at 1-800-532-1275. If you live in Polk County, call 243-1193.

Policy Regarding Discrimination, Harassment,

Affirmative Action and Equal Employment Opportunity

It is the policy of the Iowa Department of Human Services (DHS) to provide equal treatment in employment and provision of services to applicants, employees and clients without regard to race, color, national origin, sex, religion, age, disability, political belief or veteran status.

If you feel DHS has discriminated against or harassed you, you can send a letter of complaint to:

Iowa Department of Human Services, Administrator, Diversity Program Unit, 1305 E. Walnut, Des Moines IA 50319-0114; phone (800) 972-2017; fax (515) 281-4243.

470-0615 (Rev. 5/09)

Iowa Department of Human Services

IV-A Decision Making

The IV-A program is designed to extend a menu of services to children who are victims or at risk of abuse, neglect, at risk of out-of-home placement, or in need of care or treatment.

1.	Does an emergency exist? Yes or No
	There is an emergency when one of the following situations exists:

1.Abuse, neglect, or abandonment of a child exists, OR risk of same.

2.Children are imminent danger where continued presence in the home is not in the best interest of the child.

3.Children have been removed from the home OR are at risk of removal from the home because of abuse, neglect, which may include homelessness, or inability of parents to provide needed care or treatment or to control the behavior of the child.

2.Did the emergency situation arise out of the applicant’s or applicant’s family’s refusal, without good cause, to

accept employment or training for employment within 30 days of the date of the application? Yes or No

3.Is the child living, or within six months prior to the month in which assistance is requested has been living, with his father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece in a place of residence maintained as the child’s own home? Yes or No

If the answer is no, the child is ineligible for IVA-EA services. This applies primarily to those children being reauthorized for services that have been placed out of the home for the previous six months.

The applicant demonstrates a need for one or more of the following services: Yes or No

•Family centered child welfare services (Safety and FSRP)

•Foster care

•Protective child care

4.Does the family meet income eligibility? Yes or No

The applicant family is receiving FIP, SSI, FA, or Medicaid in the month of the application or does not have cash to provide needed emergency care or services as evidenced by the applicant family having an income which does not exceed the 800% of the poverty guidelines established by the Office of Management and Budget. The social worker does not need to verify the income level reported. They can simply take the statement of the family.

Services to families and children provided through the emergency assistance program as a result of a single application may be provided for either a period not to exceed 12 months, or until there is no longer a need for services according to eligibility criteria for the specified services, whichever comes first.

The IVA service will need to be reviewed annually. A FACS Alert will come 30 days prior to the due date for review. Staff will need to go through a similar process upon re-authorization as for initially authorization. Review the case to determine if the child/family still meets the criteria for services.

2009 NATIONAL POVERTY Guidelines

800% of Poverty

Household		1		2		3		4		5		6		7		8	Per Person
Size																	Additional
Annual	$	86,640	$	116,560	$	146,480	$	176,400	$	206,320	$	236,240	$	266,160	$	296,080	$	29,920
Monthly	$	7,220	$	9,714	$	12,207	$	14,700	$	17,194	$	19,687	$	22,180	$	24,674	$	2,494

470-0615 (Rev. 5/09)