In the heart of Pennsylvania, residents seeking assistance through various welfare programs encounter a crucial step in the process: the Pa 600R form. This document, issued by the Commonwealth of Pennsylvania Department of Public Welfare, serves as a comprehensive review mechanism for individuals currently benefiting from or applying for cash, medical, and food stamps benefits. Its importance cannot be overstated, as it ensures the continuation of support without interruption. To fulfill this role effectively, the form demands thorough completion and a clear understanding of its sections, which cover everything from basic client information and household composition to income, resources, and expenses details. A distinctive feature of the Pa 600R is its ability to not only review but also update personal information, allowing for the addition of new household members or the reporting of significant life changes that could affect eligibility. Additionally, the form plays a part in civic engagement by including a voluntary voter registration section, highlighting the interconnectedness of social welfare and community participation. Completing the Pa 600R requires attention to detail and promptness—attributes that have a direct impact on the livelihood of those it serves.
| Question | Answer |
|---|---|
| Form Name | Pa 600R Form |
| Form Length | 10 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 30 sec |
| Other names | what is a pa600r, pa600r, pa600r form, pa 600 r sg 8 14 |
BENEFITS REVIEW |
COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOF PUBLIC WELFARE |
We must review your eligibility for cash, medical and/or food stamps benefits.
To continue receiving benefits without delay, complete the entire form and sign page 8, then:
Bring this completed form to your interview
See attached instructions for a telephone interview
If you want to add a new person, call your caseworker.
IMPORTANT NOTICE TO RECIPIENT
Please complete the following steps for use of the benefits review form.
1.Complete the form to the best of your ability. If you need help, another person can help you or you can get help from your County Assistance Office.
2.Sign and date the benefits review form.
3.Bring it to the County Assistance Office on the date and time of your scheduled interview. If you are to have a telephone interview, mail the form with any verification requested to your caseworker.
INSTRUCTIONS
Please print clearly. Try to complete as much information as possible. The information requested on this form is needed to determine your continued eligibility.
It is important that you read the Rights and Responsibilities on page 7 and the Affidavit on page 8.
CLIENT INFORMATION
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LAST NAME |
FIRST NAME |
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MIDDLE INITIAL |
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TELEPHONE NUMBER |
SCHOOLDISTRICT |
TOWNSHIP |
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1
OTHER PROGRAMS
IF YOU WOULD LIKE TO KNOW MORE ABOUT OTHER PROGRAMS FOR YOU AND YOUR CHILDREN, PLEASE CHECK BOXES BELOW.
HOUSING ASSISTANCE
FOOD BANKS
IMMUNIZATIONS (Shots)
FAMILYPLANNING/BIRTH CONTROL
ENERGYASSISTANCE
WOMEN, INFANTS AND CHILDREN (WIC)
NUTRITION PROGRAM
WELLBABYCLINIC
HEAD START(KidsAge 3 thru 6)
CHILD CARE
CHILD SUPPORTSERVICES
FREE OR REDUCED COSTSCHOOLMEALS
SUPPLEMENTALSECURITYINCOME (SSI)
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DO NOTCOMPLETE |
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COUNTYASSISTANCE OFFICE USE |
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WORKER I.D. |
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CASELOAD |
RECORD NUMBER |
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NAME |
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APPOINTMENT DATE/TIME |
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AUTHORIZED NOTAUTHORIZED
DATE
BY
CAT
REASON
CODE
PA600 R (SG) 11/09
PLEASE PRINT
LIST YOURSELF FIRST, THEN LIST EVERYONE WHO LIVES WITH YOU
OFFICE |
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ENTER YOUR NAME FIRST |
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AREYOU |
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JR/SR |
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I, II |
THISPERSON? |
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LASTNAME |
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YES NO |
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SOCIAL
SECURITY
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UNEARNED INCOME |
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PERSON HAVE A |
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PAACCESS CARD |
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MONTHLYINCOME |
SOURCE |
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EXPLAIN ALLCHANGES SINCE YOUR LAST REVIEW |
LIST CHANGES |
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YES |
NO |
INCOME CHANGES |
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NO |
RESOURCE CHANGES |
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HOUSEHOLD CHANGES |
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CHILD CARE ARRANGEMENTS / CHANGE |
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PA600 R (SG) 11/09 |
2 |
VOTER REGISTRATION (Optional)
If you or any other adult in your household is not registered to vote where you live now, would you like to register to vote? __Yes __No
If yes, enter names below. IFYOUDO NOT CHECK ‘YES’OR ‘NO’, you are choosing not to register to vote at this time.
To register you must: 1) Be at least age 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION; 3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.
LINE NO
CAO ONLY
LASTNAME
FIRST NAME
LINE NO
CAO ONLY
LAST NAME
FIRST NAME
YOURBENEFITSWILLNOTBEAFFECTEDIFYOUREGISTERORDONOTREGISTER.
Ifyouneedhelpfillingoutthevoterregistrationform,wewillhelpyou.Thedecisionwhethertoseekoraccepthelpisyours.Youmayfillouttheapplicationforminprivate. Pleasecontactthecountyassistanceofficeifyouneedhelp.Ifyoubelievethatsomeonehasinterferedwithyourrighttoregistertovote,ortodeclinetoregistertovote,yourrightto privacyindecidingwhethertoregisterorinapplyingtoregistertovote,oryourrighttochooseyourownpoliticalpartyorotherpoliticalpreference,youmayfileacomplaintwiththe
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■ Given to client ___/___/____ |
■ Sent to voter registration ___/___/____ |
■ Mailed to client ___/___/____ |
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■ Declined, not interested ___/___/____ |
■ Not a U.S. citizen ___/___/____ |
■ Declined, already registered ___/___/____ |
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YES |
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If employed, is medical insurance available for you or anyone in your family? |
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Did you (or someone in the family) lose a job within the past 30 days where you had medical insurance? |
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Is there someone in your family who is pregnant? |
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NO - Is anyone disabled, blind, seriously ill, or in need of special medical care or help to overcome a drug or alcohol problem? |
If yes, provide information below. |
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NAME OF PERSON WHO IS ILLOR DISABLED |
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DESCRIBE THE ILLNESS OR DISABILITY |
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PREGNANCYDUE DATE |
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NAME OF DOCTOR OR CLINIC |
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ADDRESS |
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WHERE DOES YOUR FAMILY |
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RECEIVE HEALTH CARE? |
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3 |
PA600 R (SG) 11/09 |
YES
NO Do you have medical insurance or does someone have medical insurance for you? If yes, list each policy below:
NAME AND ADDRESS OF INSURANCE COMPANY |
CONTRACT/POLICY# |
GROUPNAME/GROUP# |
POLICYHOLDER NAME ADDRESS AND SOCIALSECURITYNUMBER |
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WHO COVERED?
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RESC |
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LIST ALLRESOURCES SUCH AS CASH, VEHICLES, STOCKS, BONDS, BANK ACCOUNTS, PROPERTY, ETC. |
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NAME OF OWNER (Last, First, MI) |
VALUE |
RESOURCE / ACCT# |
VALUE |
NAME OF OWNER (Last,First, MI) |
VALUE |
RESOURCE / ACCT# |
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EXPE
ANSWER THE FOLLOWING QUESTIONS
YES
YES
YES
NO |
ARE YOU OR ANYONE ELSE IN YOUR HOUSE RESPONSIBLE FOR HEATING AND/OR |
WHATARE YOUR MONTHLYMEDICAL |
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COOLING COSTS AND EXPENSES? |
EXPENSES FOR ANYONE WHO IS |
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HAVE YOU GOTTEN ENERGYASSISTANCE SINCE OCT. 1? |
AGE 60 OR OLDER OR DISABLED? |
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DO YOU SHARE EXPENSES? IF YES, WITH WHOM?________________________________________ PLEASE LISTSHARED EXPENSES |
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AND AMOUNTYOU CONTRIBUTE_____________________________________________________________________________________________ |
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SHEL |
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LIST YOUR HOUSEHOLD EXPENSES BELOW |
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EXPENSES |
HOW MUCH |
HOW OFTEN |
EXPENSES |
HOW MUCH |
HOW OFTEN |
EXPENSES |
HOW MUCH |
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HOW OFTEN |
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RENTOR MORTGAGE |
$ |
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ELECTRIC |
$ |
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SEWERAGE |
$ |
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PROPERTYTAXES |
$ |
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GAS |
$ |
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GARBAGE |
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HOMEOWNERS |
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OIL/COAL/WOOD |
$ |
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UTILITYINSTALLATION |
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PROPERTYINSURANCE |
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TELEPHONE |
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WATER |
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OTHER SUCH AS LOT |
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RENT, KEROSENE, ETC. |
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YES
NO Is there anyone outside your household |
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who pays any expenses? |
If so, what? |
How much?
To who?
DOES ANYONE IN YOUR HOUSEHOLD WHO IS WORKING, LOOKING FOR WORK, OR GOING TO SCHOOLOR TRAINING PAYANYEXPENSES RELATED TO THE CARE OF ACHILD OR DISABLED ADULTIN YOURHOUSEHOLD?
YES
NO
MONTHLYAMOUNT
HOW MUCH DO YOU PAYTO TRAVELTO WORK? $
HOW DO YOU TRAVEL(Bus, Train, Car, Subway)?
MILES
IF YOU USE YOUR CAR - HOW MANYROUND TRIPMILES TO WORK?
HOW MANYDAYS EACH WEEK?
DO YOU OR ANOTHER HOUSEHOLD MEMBER PAYCHILD SUPPORTTO APERSON WHO DOES NOTLIVE WITH YOU?
IF YES, IS ITVOLUNTARYOR |
VOLUNTARY |
COURTORDERED |
YES
NO
PA600 R (SG) 11/09 |
4 |
USE THIS PAGE FOR PARENTS AND/OR ASPOUSE NOT LIVING IN YOUR HOUSEHOLD. |
ABS REL |
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YES YES
NO NO
Does any unmarried child under 21 have a mother or father who is not living with you or who is deceased? Does anyone have a husband or wife who is not living with you or who is deceased?
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If you answered yes to either or both questions, give the following information for each relative. |
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Complete a separate section for each relative. |
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NAME OF RELATIVE (Last, First, Middle) |
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IF DECEASED |
SEX |
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RACE |
BIRTHDATE (MO/DAY/YR) |
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SOCIALSECURITY# |
HOW IS THIS PERSON RELATED TO YOU |
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ADDRESS (Street, City, State) |
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ZIPCODE |
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NAME OF RELATIVE’S EMPLOYER (Current or most recent) |
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EMPLOYER’S ADDRESS (Street, City, State) |
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ZIPCODE |
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PHONE NUMBER |
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NAMES FROM PAGE 2 THATTHIS PERSON IS RESPONSIBLE FOR |
IF THE RELATIVE HAS MEDICALINSURANCE FOR THESE DEPENDENTS, COMPLETE THE POLICY# AND COMPANY |
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COMPANY |
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IF THIS RELATIVE PAYS SUPPORTOR IF HE OR SHE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING: |
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HOW MUCH |
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HOW OFTEN |
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LASTDATE PAID (MO/DAY/YR) |
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PAID TO WHOM |
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VOLUNTARYSUPPORT |
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FOR COURT |
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COURTORDER # |
AMOUNT |
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HOW OFTEN IS ITPAID |
DATE OF ORDER (MO/DAY/YR) |
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WHATARE THE SPECIALTERMS |
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COURTNAME |
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ORDERED |
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NAME OF RELATIVE (Last, First, Middle) |
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IF DECEASED |
SEX |
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RACE |
BIRTHDATE (MO/DAY/YR) |
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SOCIALSECURITY# |
HOW IS THIS PERSON RELATED TO YOU |
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ADDRESS (Street, City, State) |
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NAME OF RELATIVE’S EMPLOYER (Current or most recent) |
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EMPLOYER’S ADDRESS (Street, City, State) |
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ZIPCODE |
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PHONE NUMBER |
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NAMES FROM PAGE 2 THATTHIS PERSON IS RESPONSIBLE FOR |
IF THE RELATIVE HAS MEDICALINSURANCE FOR THESE DEPENDENTS, COMPLETE THE POLICY# AND COMPANY |
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COMPANY |
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IF THIS RELATIVE PAYS SUPPORTOR IF HE OR SHE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING: |
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FOR |
HOW MUCH |
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HOW OFTEN |
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LASTDATE PAID (MO/DAY/YR) |
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VOLUNTARY |
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FOR COURT |
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COURTORDER # |
AMOUNT |
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HOW OFTEN IS ITPAID |
DATE OF ORDER (MO/DAY/YR) |
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WHATARE THE SPECIALTERMS |
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COURTNAME |
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5 |
PA600 R (SG) 11/09 |