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5.8 Jim Ashmore 3


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5.8 Jim Ashmore 3

  1. 1. Customer Document <br /> Receipt<br />Library Branch: FORMTEXT      Phone: FORMTEXT      Customer: Sign to verify you requested that the items checked below be scanned and transferred to HCJFS.Library Staff: Sign here to verify all items checked below were scanned.# of pages scanned: (including this page) FORMTEXT      Date: FORMTEXT      PRINT Your Name:Important:If you do NOT hear from your caseworker within 10 calendar days of the date above, call 946-1000.Address:Social Security Number:Phone: (where you can be reached)Your Caseworker’s Name: (Leave this blank if you don’t know.)The Documents We Are Scanning & Transferring to HCJFS Are About:You and your familyQuantityYou and your family’s healthSocial Security Card(s)Physician statement Pregnancy statementStatement of disabilitySpend-down verificationsYour child support (items not listed elsewhere) Divorce decreeMarriage licenseChild Support orderChild Support Order Modification RequestEmancipation informationYour child careSchool schedule or letter from schoolWork schedule or letter from your employerApplicationsJFS 07200 – Request for Cash, Food, and Medical Assistance JFS 07216 – Combined Programs Application (CPA) HCJFS 0399-A – Prevention, Retention & ContingencyJFS 01138 –Application for Child Care BenefitsOther: (please list)Photo Identification(s)Birth Certificate(s)Passport(s)Shot record(s)Report card(s)Your job/resources & how much money you earnEmployment Verification FormIncome Verification FormPaycheck Stub(s)Award Letter from Social Security,Veterans, or InsuranceBank StatementCar Title – RegistrationWhy your job endedLetter from your employer stating: why your job ended, date your job ended, amount of your last paycheck.Where you liveHousehold Verification Change of AddressLease AgreementMortgage book Utility billRent ReceiptHCJFS Use Only:FAA 1FAA 2FAA 3IM/PIChildren’s Services Child Day Care Child SupportHealth ServicesSSI Case Management Other:<br />