Form Pa 162Vr PDF Details

When individuals in Pennsylvania apply for or receive public assistance benefits, the Commonwealth of Pennsylvania's Department of Public Welfare, through its Office of Income Maintenance, plays a crucial role in ensuring that the benefits are accurately distributed. This process involves verifying the financial information of applicants or beneficiaries to maintain integrity and fairness in the distribution of public assistance funds. The Pa 162Vr form serves as a vital communication tool in this verification process. It is sent to those whose social security numbers, including those of household members, have provided financial information that either wasn't reported during the application process or conflicts with previously provided information. This form outlines the sources of the unreported or conflicting financial data, type and amount of income received, payee details, relevant periods, and the frequency of the income received. Recipients of this form are required to provide additional verification to clear up any discrepancies. Verification can vary but must be provided either by mail by a specified deadline or in person, with the form giving clear instructions on how to do so, including a deadline for submission, and where to send or bring the required documentation. Additionally, the form provides contact information for assistance, highlighting the department's commitment to keeping applicants informed and engaged in the maintenance of their eligibility for public assistance benefits. This thorough process ensures that assistance is provided fairly and to those who genuinely qualify, making forms like the Pa 162Vr an essential component of the welfare system in Pennsylvania.

QuestionAnswer
Form NameForm Pa 162Vr
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 162, 162vr, pa 162vr pdf, pa162 vr

Form Preview Example

COMMONWEALTHOFPENNSYLVANIA

DEPARTMENTOFPUBLICWELFARE

OFFICE OF INCOME MAINTENANCE

Dear

Because you have applied for/or receive PUBLIC ASSISTANCE benefits, your social security number and the social security numbers of the people in your household have been used to obtain information from other government agencies.

The information we have received follows:

SOURCE:

 

 

 

 

INCOMETYPE

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

 

 

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

FREQUENCY:

 

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

CONTINUED ON BACK

 

 

 

 

 

 

 

This information was not reported when you applied for public assistance or it conflicts with information you gave to your eligibility worker. In order for us to determine if this information is correct and/or affects your public assistance benefits, you must provide additional verification. Verification which may be acceptable includes

Be sure to put your name, address and record number on the information you provide.

Please mail this information by

/

/

to the office shown above.

Attention

Please bring this information to the COUNTYASSISTANCE OFFICE at the above address on

 

 

 

at

 

 

 

 

.

 

This information is required

so

we can

determine

your continued eligibility for benefits. If

you have any questions concerning

this

 

request,

or need

help to get verification, please call your

eligibility worker immediately at

 

 

 

 

 

 

. Thank you.

Worker’s Signature

Date

CO

RECORD NO.

CAT

 

 

 

DIST

CS LD

CLIENT

CASE RECORD

PA162VR - 12/07

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

SOURCE:

 

 

 

 

 

 

INCOMETYPE

 

 

AMOUNT: $

 

 

 

 

PAIDTO:

 

 

 

 

 

 

 

 

PERIOD:

 

 

 

 

SOCIALSECURITYNUMBER:

 

 

 

 

 

 

 

 

PAID BY:

 

 

 

 

 

 

 

 

 

 

 

FREQUENCY:

 

CLAIM /ACCOUNTNUMBER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS: