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GEORGIA DEPARTMENT OF HUMAN RESOURCES
LEGAL SERVICES REQUEST/REPORT
DFCS Client Identification (for Accounting purposes)
Date:       Card ID#      
From:       Parent’s Name      
(County Dept. of Family and Children Services)
      Children’s Name      
Worker:            
      Program Area – CHECK ONE
(Attorney)
     
Child Protective Services
Adult Protective Services
     
Foster Care
Adoption
(Address)
      Eligibility Status (CHECK ONLY ONE)
     
Recipient of AFDC
Recipient of SSI
Income Eligible Scale 1
Without Regard to Income (Protective
Services Case)
None of the above. Policy waiver attached.
CHECK AND COMPLETE AS APPROPRIATE:
Legal consultation only. Briefly describe reasons and/or issues necessitating need for consultation.
Legal representation (including consultation). Describe services needed and reasons for referral.
LIST ALL LEGAL ACTIVITY ON CASE FOR MONTH SUBMITTED INCLUDING DATE, ACTIVITY AND
TIME INVOLVED:
Legal Services concluded:      
PREPARATION AND ROUTING: Prepare in triplicate. Send original to SSC/County Program Director
(CPD). Submit SSC/CPD copy by the 10th
of each month.
CW_510 Legal Services Request/Report (Rev. 09/06) Page 1 of 1

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Cw 510 legal services request report

  • 1. GEORGIA DEPARTMENT OF HUMAN RESOURCES LEGAL SERVICES REQUEST/REPORT DFCS Client Identification (for Accounting purposes) Date:       Card ID#       From:       Parent’s Name       (County Dept. of Family and Children Services)       Children’s Name       Worker:                   Program Area – CHECK ONE (Attorney)       Child Protective Services Adult Protective Services       Foster Care Adoption (Address)       Eligibility Status (CHECK ONLY ONE)       Recipient of AFDC Recipient of SSI Income Eligible Scale 1 Without Regard to Income (Protective Services Case) None of the above. Policy waiver attached. CHECK AND COMPLETE AS APPROPRIATE: Legal consultation only. Briefly describe reasons and/or issues necessitating need for consultation. Legal representation (including consultation). Describe services needed and reasons for referral. LIST ALL LEGAL ACTIVITY ON CASE FOR MONTH SUBMITTED INCLUDING DATE, ACTIVITY AND TIME INVOLVED: Legal Services concluded:       PREPARATION AND ROUTING: Prepare in triplicate. Send original to SSC/County Program Director (CPD). Submit SSC/CPD copy by the 10th of each month. CW_510 Legal Services Request/Report (Rev. 09/06) Page 1 of 1