The PA 600R form, also known as the Benefits Review form, is a crucial document provided by the Commonwealth of Pennsylvania Department of Public Welfare. It serves to review an individual's eligibility for receiving cash, medical, and/or food stamps benefits ensuring continued support without disruption. Recipients are required to complete and sign this form, following specific steps outlined for submission, to facilitate a smooth assessment process.
Ensuring the continuity of benefits for individuals and families in need is a critical component of the social safety net provided by the Commonwealth of Pennsylvania. The PA 600R form, a Benefits Review document formulated by the Department of Public Welfare, serves as a pivotal tool in this process. This comprehensive form is designed to assess eligibility for cash, medical, and food stamp benefits, requiring recipients to thoroughly complete and sign it to avoid any interruption in their aid. The necessity of completing this form accurately and promptly cannot be overstated, as it directly impacts the well-being of countless Pennsylvanians. Alongside verifying continued eligibility, the form offers an opportunity for recipients to explore additional programs such as housing assistance, immunizations, and nutrition programs, which can further support their path to stability and health. Furthermore, the form includes provisions for voter registration, emphasizing the state's commitment to not only aid its residents in meeting basic needs but also encourage civic participation. Completing the PA 600R form is a detailed process that involves submitting personal and financial information, along with changes in household composition or income since the last review, ensuring that assistance is accurately tailored to current needs. This process underscores the importance of maintaining a transparent and up-to-date dialogue between beneficiaries and the Department of Public Welfare, fostering a system of support that adapts to the evolving circumstances of those it serves.
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
LAST NAME
FIRST NAME
MIDDLE INITIAL
STREETADDRESS
CITY
ST
ZIPCODE
TELEPHONE NUMBER
SCHOOLDISTRICT
TOWNSHIP
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)
DO NOTCOMPLETE
COUNTYASSISTANCE OFFICE USE
WORKER I.D.
CASELOAD
RECORD NUMBER
CAT
NAME
APPOINTMENT DATE/TIME
AUTHORIZED NOTAUTHORIZED
DATE
BY
REASON
CODE
PA600 R (SG) 11/09
PLEASE PRINT
LIST YOURSELF FIRST, THEN LIST EVERYONE WHO LIVES WITH YOU
OFFICE
ENTER YOUR NAME FIRST
AREYOU
BIRTHDATE
SEX
USE
JR/SR
APPLYINGFOR
LINE
I, II
THISPERSON?
LASTNAME
FIRST
MI
YES NO
MO DAY YR
M F
NO.
SOCIAL
SECURITY
NUMBER
NO. OF HOURS WORKED PER WEEK
LISTALLEARNED AND
DOES THIS
UNEARNED INCOME
PERSON HAVE A
PAACCESS CARD
GROSS
INCOME
YES
NO
MONTHLYINCOME
SOURCE
EXPLAIN ALLCHANGES SINCE YOUR LAST REVIEW
LIST CHANGES
INCOME CHANGES
RESOURCE CHANGES
HOUSEHOLD CHANGES
CHILD CARE ARRANGEMENTS / CHANGE
OTHER CHANGES
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
YOURBENEFITSWILLNOTBEAFFECTEDIFYOUREGISTERORDONOTREGISTER.
Ifyouneedhelpfillingoutthevoterregistrationform,wewillhelpyou.Thedecisionwhethertoseekoraccepthelpisyours.Youmayfillouttheapplicationforminprivate. Pleasecontactthecountyassistanceofficeifyouneedhelp.Ifyoubelievethatsomeonehasinterferedwithyourrighttoregistertovote,ortodeclinetoregistertovote,yourrightto privacyindecidingwhethertoregisterorinapplyingtoregistertovote,oryourrighttochooseyourownpoliticalpartyorotherpoliticalpreference,youmayfileacomplaintwiththe SecretaryoftheCommonwealth,PADepartmentofState,Harrisburg,PA17120.(Toll-freetelephonenumber1-877-VOTESPA.)
DONOTCOMPLETE-COUNTYASSISTANCEOFFICEUSE
■ Given to client ___/___/____
■ Sent to voter registration ___/___/____
■ Mailed to client ___/___/____
■ Declined, not interested ___/___/____
■ Not a U.S. citizen ___/___/____
■ Declined, already registered ___/___/____
HIPP
-
If employed, is medical insurance available for you or anyone in your family?
Did you (or someone in the family) lose a job within the past 30 days where you had medical insurance?
Is there someone in your family who is pregnant?
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.
NAME OF PERSON WHO IS ILLOR DISABLED
DESCRIBE THE ILLNESS OR DISABILITY
PREGNANCYDUE DATE
NAME OF DOCTOR OR CLINIC
ADDRESS
WHERE DOES YOUR FAMILY
RECEIVE HEALTH CARE?
3
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
WHO COVERED?
RESC
LIST ALLRESOURCES SUCH AS CASH, VEHICLES, STOCKS, BONDS, BANK ACCOUNTS, PROPERTY, ETC.
NAME OF OWNER (Last, First, MI)
VALUE
RESOURCE / ACCT#
NAME OF OWNER (Last,First, MI)
$
EXPE
ANSWER THE FOLLOWING QUESTIONS
ARE YOU OR ANYONE ELSE IN YOUR HOUSE RESPONSIBLE FOR HEATING AND/OR
WHATARE YOUR MONTHLYMEDICAL
COOLING COSTS AND EXPENSES?
EXPENSES FOR ANYONE WHO IS
HAVE YOU GOTTEN ENERGYASSISTANCE SINCE OCT. 1?
AGE 60 OR OLDER OR DISABLED?
DO YOU SHARE EXPENSES? IF YES, WITH WHOM?________________________________________ PLEASE LISTSHARED EXPENSES
AND AMOUNTYOU CONTRIBUTE_____________________________________________________________________________________________
SHEL
LIST YOUR HOUSEHOLD EXPENSES BELOW
EXPENSES
HOW MUCH
HOW OFTEN
RENTOR MORTGAGE
ELECTRIC
SEWERAGE
PROPERTYTAXES
GAS
GARBAGE
HOMEOWNERS
OIL/COAL/WOOD
UTILITYINSTALLATION
PROPERTYINSURANCE
TELEPHONE
WATER
OTHER SUCH AS LOT
RENT, KEROSENE, ETC.
NO Is there anyone outside your household
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?
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 COURT-ORDERED?
VOLUNTARY
COURTORDERED
4
USE THIS PAGE FOR PARENTS AND/OR ASPOUSE NOT LIVING IN YOUR HOUSEHOLD.
ABS REL
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?
If you answered yes to either or both questions, give the following information for each relative.
Complete a separate section for each relative.
NAME OF RELATIVE (Last, First, Middle)
IF DECEASED
RACE
BIRTHDATE (MO/DAY/YR)
SOCIALSECURITY#
HOW IS THIS PERSON RELATED TO YOU
ADDRESS (Street, City, State)
PHONE NUMBER
NAME OF RELATIVE’S EMPLOYER (Current or most recent)
EMPLOYER’S ADDRESS (Street, City, State)
NAMES FROM PAGE 2 THATTHIS PERSON IS RESPONSIBLE FOR
IF THE RELATIVE HAS MEDICALINSURANCE FOR THESE DEPENDENTS, COMPLETE THE POLICY# AND COMPANY
POLICY
NAME OF
INSURANCE
COMPANY
IF THIS RELATIVE PAYS SUPPORTOR IF HE OR SHE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING:
FOR
LASTDATE PAID (MO/DAY/YR)
PAID TO WHOM
VOLUNTARYSUPPORT
FOR COURT
COURTORDER #
AMOUNT
HOW OFTEN IS ITPAID
DATE OF ORDER (MO/DAY/YR)
WHATARE THE SPECIALTERMS -IF ANY
COURTNAME
ORDERED
SUPPORT
5
CRIMINAL HISTORY INQUIRY
Please answer the following questions for yourself and anyone else for whom you are applying. If you answer “yes” to a question, list the name of the household member(s) to whom the “yes” answer applies.
1.
■ YES
■ NO
Have you or anyone for whom you are applying been issued a summons or warrant to appear as a defendant at a criminal
court proceeding? If YES, who? ________________________________________________________________________
2.
Do you or anyone for whom you are applying owe fines, costs, or restitution for a felony or misdemeanor offense?
If YES, who? ________________________________________________________________________________________
3.
Have you or anyone for whom you are applying been convicted of welfare fraud?
4.
Are you or anyone for whom you are applying currently on probation or parole?
5.
Are you or anyone for whom you are applying currently fleeing from law enforcement officials?
FAMILYSAFETY Information About Your Benefits and Domestic Violence
Domestic Violence happens when someone in your life harms you physically, sexually or emotionally, including:
Physically hurting you or your children
Controlling where you go and who you see
Threatening or trying to hurt you, your children or your property
Not allowing you or your children to have food, clothing or medical care
Forcing you to have sex
Keeping you from going to work or school
Sexually abusing your children
Following or stalking you
If you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can:
Help you find local programs where you can get counseling, safety planning, shelter, legal services and other help.
Excuse you from requirements for cash assistance if domestic violence prevents you from complying: Sometimes people cannot safely follow welfare requirements because they fear that they or their children will be abused if they do so. These include:
Support cooperation
Requirements that teen parents live at home
WORK (RESET)
Verification
Time limits
Other requirements on a case-by-case basis
If you need to be excused from welfare requirements because of domestic violence, tell your caseworker.
You can ask to speak to your caseworker in private. you may not want to share this information with your caseworker or you may decide to discuss it with your worker later. Your caseworker and the staff at the county assistance office will keep your personal information confidential. However, the Department of Public Welfare is required by law to report child abuse to the local Children and Youth Agency.
6
CLIENT RIGHTS
RIGHT TO NONDISCRIMINATION - We may not discriminate on the basis of age, sex, race, color, ancestry, disability, religious creed, national origin, sexual preference, life-style, union membership, political belief, or because you applied for and/or received assistance before. If you feel you have been discriminated against by the Department or anyone providing services for the Department, you may file a verbal or written complaint with the Department or the County Assistance Office which will forward the complaint to the appropriate federal or state agency.
RIGHT TO APPEAL - You have the right to ask for a Departmental hearing to appeal a decision of or failure to act by the Department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the County Assistance Office. At the appeal hearing, you may represent yourself or someone else, such as a lawyer, friend, or relative may represent you.
RIGHT TO AN AGENCY CONFERENCE - If you appeal, you may have an agency conference before the hearing. If you appeal because the Department decided that you are not eligible for expedited food stamp service, you have a right to an agency conference with a supervisor within 2 work days.
RIGHT TO A WRITTEN NOTICE - We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days (90 days for food stamps) from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.
CHILD CARE PROVIDER INFORMATION - You have the right to request a child abuse and criminal background clearance from your child care provider.
RIGHT TO CONFIDENTIALITY - We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for, such as the school lunch program. Any person knowingly violating any of the rules and regulations of this Department made in accordance with this article shall be guilty of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine, not exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both (62 P.S. Section 483).
The CAO, when requested, must provide federal, state and local law enforcement officials with the address, Social Security Number, and photograph (if available) of an individual who is fleeing to avoid prosecution, custody, or confinement for a felony or violating probation or parole.
RIGHT TO CLAIM GOOD CAUSE - The law requires you to cooperate in establishing paternity for any child born out of marriage and get any support owed to you and/or any child(ren) for whom you want cash and/or medical assistance. The Department will excuse you from cooperating with the support requirements if you prove that it would not be in the best interest of the child(ren) for whom assistance is claimed.
If you are not exempt from employment and training requirements, you must comply unless you have good cause. You must meet Monthly Reporting requirements unless you have good cause.
CLIENTRESPONSIBILITIES
RESPONSIBILITY TO ACKNOWLEDGE LIABILITY OF REAL OR PERSONAL PROPERTY - If you are applying for cash assistance and have non-resident real property and/or personal property, we may require you to sign an agreement to repay benefits received by you, your spouse, and minor children.
If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you will be required to repay the cost of these services from your probate estate.
RESPONSIBILITY TO PROVIDE INFORMATION - You must give true, correct and complete information. You must cooperate in documenting or proving the information you give. Cash assistance may be denied if you fail to provide certain verification. If you cannot provide proof, you should ask the County Assistance Office to help. You must cooperate fully with persons or investigators of the Department or the Inspector General’s Office conducting investigations.
RESPONSIBILITY TO REPORT CHANGES -For cash assistance and Medical Assistance, you must report changes in: the number of people in your household, address, new unearned income, real property or other resources (such as bank accounts or life insurance). However, for Medical Assistance, if you are pregnant, under 21 years of age or have a dependent child under 21 years of age living with you, you are not required to report changes in resources. You must report any plans to leave the state, even temporarily. If you have no earned income, you must report new employment or new income from self-employment. If you have earned income, you must report if your gross monthly earned income increases by more than $100 than the estimated gross monthly earned income used to determine your benefit. If you have unearned income, you must report if your gross monthly unearned income increases by more than $50 than the amount used to determine your benefit. You must report changes within the first 10 days of the month following the month of the change.
For Food Stamp households that are not participating in Semiannual Reporting (SAR), you must report changes as described for cash assistance with three exceptions. If you have unearned income, you must report increases or decreases in gross monthly unearned income of more than $50. Additionally, changes in life insurance and temporary absences from the state or county do not need to be reported.
For Food Stamp households that are participating in SAR, you must report if your household's total gross monthly income exceeds 130 percent of the Federal Income Poverty Guidelines (FPIGs) for your household size. The report must be made within 10 calendar days from the end of the month in which the gross monthly income exceeds the 130 percent FPIGs. Your caseworker will explain your specific income reporting requirement.
In addition, for Food Stamp households that contain an Able-Bodied Adult Without Dependents (ABAWD) that are participants in SAR, the household must report if the ABAWD work hours fall below an average of 20 hours weekly. An ABAWD means that you are able to work, you are age 18 through 49 and you have no children under age 18 who live with you.
If you are proven to have failed, without good cause, to report earned income in a timely manner, you may not receive an earned income deduction on the unreported income. This may reduce the amount of cash assistance and/or Food Stamps to which you are entitled and increase the amount of the overpayment claim.
You can report changes to the CAO in person, by telephone, by fax or by mail.
RESPONSIBILITY TO LAWFULLY USE THE PA ACCESS CARD - You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only services that are needed and reasonable.
RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS - For cash, medical and/or food stamps benefits, you must provide a Social Security Number (SSN) for each person for whom you are applying. If you do not have an SSN you must apply for one. Refusal or failure to provide an SSN may result in dis- qualification. For cash and medical benefits, we will also ask you to supply an SSN for anyone else whose income and/or resources affect your eligibility or amount of benefits. We use the SSN to verify identity, administer our programs, prevent duplication in state and federal programs, for computer matches with other programs, and to get information about income and resources to determine eligibility for, and/or he amount of, your benefits (42 U.S.C. § 1320b-7)
You must NOT:
•give false, incorrect, or incomplete information;
•trade, sell or alter your food stamps or your Authorization To Participate (ATP), Electronic Benefit Transfer (EBT) Card or your PA ACCESS Card;
•use other people’s food stamps, ATP’s, EBT, or PA ACCESS Card;
•use your food stamps to buy ineligible items, such as alcoholic drinks or tobacco; OR
•use your food stamps to buy illegal drugs, firearms, ammunition, or explosives.
Any member of your household who is found guilty by a court or an Administrative Disqualification hearing of breaking any of the above rules or who signs a voluntary disqualification consent agreement or waiver of Administrative Disqualification hearing will be barred from getting cash assistance or food stamps for up to:
•12 months for the first violation;
•24 months for the second violation; AND
•permanently for the third violation.
Any household member found guilty by a court of having used food coupons to buy illegal drugs will be disqualified for:
•24 months for the first violation; AND
•permanently for the second violation.
Any household member found guilty by a court of buying or selling food stamp coupons, ATP cards, or other benefit instruments for cash or consideration other than food or the exchange of firearms, ammunition, explosives, or controlled substances in the amount of $500 or more in food stamp coupons will be disqualified permanently.
Any household member found by a court or an administrative disqualification hearing of misrepresenting his identity or residence to receive multiple food stamps will be disqualified for 10 years.
PROHIBITIONS AND PENALTIES
Any household member fleeing to avoid prosecution, custody, or confinement for a felony, or attempted felony, or violating a condition of probation or parole will be ineligible until the situation is rectified.
An individual who has been sentenced for a felony or misdemeanor offense and who has not satisfied the penalty imposed by the court is ineligible for Cash Assistance.
An individual is ineligible for Cash Assistance for a period of 10 years if he is convicted of fraudulent misrepresentation of residence for the purpose of receiving welfare benefits in two or more states.
Cash Assistance will be reduced by amounts received by cashing an assistance check at a gambling casino, race track, bingo hall or other establishment that derives more than 50% of its gross revenues from gambling.
If you do not report changes as required, your benefits may be reduced or stopped. If you purposely fail to give correct information or report changes, you may be fined and/or put in jail. Improper use of the PA ACCESS Card for medical services and/or cash and food stamp electronic benefit transfers may result in a fine or imprisonment, or both.
If you are found guilty of violating these rules, or committing fraud, you also may be:
•fined up to $250,000 for food stamps and up to $15,000 for cash;
•jailed up to 20 years for food stamps and up to 7 years for cash; AND/OR
•required to repay the benefits you received.
FOOD STAMP WORK REQUIREMENTS/SANCTIONS - If you are physically and mentally
fit, over 15 years of age and under 60 years of age, and not otherwise exempt, you may not refuse to register for employment; participate in an approved employment and training pro- gram unless you have good cause; accept employment unless you have good cause; pro- vide sufficient information to your County Assistance Office about your employment status and job availability unless you have good cause or comply with workfare. Additionally, you must not voluntarily and without good cause quit your job or reduce the number of hours you work if, after the reduction, you are employed less than 30 hours per week.
If you or another member of your household violates any of the above work requirements, you or that person may be disqualified from receiving food stamps. Before a disqualification is imposed, you will receive a notice and will have the right to appeal and have a fair hearing.
The minimum disqualification periods are as follows: for the first violation, 1 month and thereafter until the failure to comply ceases; the second violation is 3 months and thereafter until the failure to comply ceases; and for the third and subsequent violations, 6 months and thereafter until the failure to comply ceases.
CASH ASSISTANCE WORK REQUIREMENTS/SANCTIONS - A mandatory participant who
fails to cooperate with the work or work-related activity requirement; participate in ETP; accept a bona fide offer of employment; or who terminates employment; reduces earnings or fails to apply for work; without good cause, is ineligible for cash assistance.
The period of sanction is:
First occurrence - 30 days or until the failure to comply ceases, whichever is longer.
Second occurrence - 60 days or until the failure to comply ceases, whichever is longer.
Third occurrence - permanently.
If the reason for sanction occurs in the first 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies only to the individual.
If the reason for the sanction occurs after the first 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies to the entire assistance group.
In place of the sanctions above, if an employed individual voluntarily, without good cause, reduces his earnings by not fulfilling the 20-hour work requirement during the first 24 months, the cash grant is reduced by the dollar value of the income that would have been earned if the recipient would have fulfilled his 20-hour work requirement, until the 20-hour requirement is met.
If an employed individual voluntarily, without good cause, reduces his earnings by not fulfilling the 20-hour work requirement after having received cash assistance for 24 months, the household is ineligible.
7
AFFIDAVIT
WHEN I SIGN THIS FORM I AGREE THAT:
•I have read this application in full or someone has read it to me and I understand the questions asked.
•I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.
•I will provide or cooperate in getting any information needed to prove my statements.
•I must report changes in my circumstances within the first 10 calendar days of the month following the month of the change, unless I am in Semiannual report- ing for Food Stamp benefits. (See pages 9 and 10 for reporting requirements.)
•I will cooperate with the requirements of the child support enforcement program as directed by the Department.
•If I receive cash and/or medical benefits, I give the state and/or the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.
•If I receive cash benefits, the worker has read the certification on the back of the check; and ever time I endorse a check, I am signing the certification.
•I am responsible for any fraudulent statements made on this application even if the application is submitted by someone acting on my behalf.
•I consent to, and will fully cooperate in the finger, photo, and signature imaging process. I understand that refusal to cooperate may result in the denial of benefits.
•I certify that, subject to penalties provided by law, that the information I gave is true, correct, and complete to the best of my knowledge.
WHEN I SIGN THIS FORM, I UNDERSTAND THAT:
•The state operates a fraud control program under which local, state, and federal officials may verify the information Ihave given. Verification will include confirmation through the Pennsylvania State Police Criminal Record Files, theAdministrative Office of Pennsylvania Court files, and other records that are available.
•The state may obtain information about my circumstances from other persons or organiza- tions, including computer matches and Immigration and Naturalization.
•My Social Security Number will be used to obtain information to verify my circumstances and eligibility.
•My benefits may be reduced or terminated or I can be penalized (including charged with fraud) for giving false or misleading information or for not reporting changes that would affect my benefits.
•I am giving the state the right to seek, with or without legal action, payment from private or public health insurance or liable third party. The amount recovered will not exceed the amount paid by medical assistance.
•The state and the Domestic Relations Section have the right to review all records of med- ical services paid for by medical assistance.
•Payment for medical services will be made directly to the provider, not to me. This includes payments from Medicare.
•The law provides for automatic assignment to the state of support rights for myself and oth- ers for whom I am accepting cash and/or medical assistance.
• If I receive cash benefits, all support including arrears will be paid to the state. If I receive medical benefits, medical support may be paid to the state. When benefits stop, arrears may be paid to the state to repay the amount of assistance granted. the amount of support retained by the state will not be more than the amount of cash assistance received and/or the amount paid under the medical assistance program.
•Failure to report or provide proof of household expenses will be regarded as my statement that I do not want to receive a deduction for unreported or unproven expenses (Authority; U.S. Department of Agriculture, Food and Nutrition Service, Mid-Atlantic region, Adminstrative Note 6-99, issued Jan. 4, 1999). I understand that I have the right to receive credit for household expenses at the time I report and that I may be asked to provide proof of them at any time during my food stamp certification period.
CLIENT OR AUTHORIZED REPRESENTATIVE SIGNATURES
ID
EMPLOYEE/WITNESS SIGNATURES
ADDRESS OF REPRESENTATIVE (STREET, CITY, STATE, ZIP)
SECOND WITNESS IF AN (X) IS SIGNED ABOVE
ADDRESS OF WITNESS
8
RIGHT TO NONDISCRIMINATION
We may not discriminate on the basis of age, sex, race, color, ancestry, disability, religious creed, national origin, sexual preference, life-style, union membership, political belief, or because you applied for and/or received assistance before. If you feel you have been discriminated against by the Department or anyone providing services for the Department, you may file a verbal or written complaint with the Department or the County Assistance Office which will forward the complaint to the appropriate federal or state agency.
RIGHT TO APPEAL
You have the right to ask for a Departmental hearing to appeal a decision of or failure to act by the Department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the County Assistance Office. At the appeal hearing, you may represent yourself or someone else, such as a lawyer, friend, or relative may represent you.
RIGHT TO AN AGENCY CONFERENCE
If you appeal, you may have an agency conference before the hearing. If you appeal because the Department decided that you are not eligible for expedited food stamp service, you have a right to an agency conference with a supervisor within 2 work days.
RIGHT TO A WRITTEN NOTICE
We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days (90 days for food stamps) from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.
CHILD CARE PROVIDER INFORMATION
You have the right to request a child abuse and criminal background clearance from your child care provider.
RIGHT TO CONFIDENTIALITY
We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for, such as the school lunch program. Any person knowingly violating any of the rules and regulations of this Department made in accordance with this article shall be guilty of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine, not exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both (62 P.S. Section 483).
RIGHT TO CLAIM GOOD CAUSE
The law requires you to cooperate in establishing paternity for any child born out of marriage and get any support owed to you and/or any child(ren) for whom you want cash and/or medical assistance. The Department will excuse you from cooperating with the support requirements if you prove that it would not be in the best interest of the child(ren) for whom assistance is claimed.
If you are not exempt from employment and training requirements, you must comply unless you have good cause.
You must meet Monthly Reporting requirements unless you have good cause.
CLIENT RESPONSIBILITIES
RESPONSIBILITY TO ACKNOWLEDGE LIABILITY OF REAL OR PERSONAL PROPERTY
If you are applying for cash assistance and have non-resident real property and/or personal property, we may require you to sign an agreement to repay benefits received by you, your spouse, and minor children.
If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and com- munity-based waiver services and any related hospital and prescription drug service, you will be required to repay the cost of these services from your probate estate.
RESPONSIBILITY TO PROVIDE INFORMATION
You must give true, correct and complete information. You must cooperate in documenting or proving the infor- mation you give. Cash assistance may be denied if you fail to provide certain verification. If you cannot provide proof, you should ask the County Assistance Office to help. You must cooperate fully with persons or investiga- tors of the Department or the Inspector General’s Office conducting investigations.
RESPONSIBILITY TO REPORT CHANGES
For cash assistance and Medical Assistance, you must report changes in: the number of people in your household, address, new unearned income, real property or other resources (such as bank accounts or life insurance). However, for Medical Assistance, if you are pregnant, under 21 years of age or have a depend- ent child under 21 years of age living with you, you are not required to report changes in resources. You must report any plans to leave the state, even temporarily. If you have no earned income, you must report new employment or new income from self-employment. If you have earned income, you must report if your gross monthly earned income increases by more than $100 than the estimated gross monthly earned income used to determine your benefit. If you have unearned income, you must report if your gross month- ly unearned income increases by more than $50 than the amount used to determine your benefit. You must report changes within the first 10 days of the month following the month of the change.
RESPONSIBILITY TO LAWFULLY USE THE PA ACCESS CARD
You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only services that are needed and reasonable.
RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS
For cash, medical and/or food stamps benefits, you must provide a Social Security Number (SSN) for each person for whom you are applying. If you do not have an SSN you must apply for one. Refusal or fail- ure to provide an SSN may result in disqualification. For cash and medical benefits, we will also ask you to supply an SSN for anyone else whose income and/or resources affect your eligibility or amount of benefits. We use the SSN to verify identity, administer our programs, prevent duplication in state and federal pro- grams, for computer matches with other programs, and to get information about income and resources to determine eligibility for, and/or he amount of, your benefits (42 U.S.C. § 1320b-7)
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•I must report any changes in my circumstances within the first 10 calendar days of the month following the month of change, unless I am in Semiannual Reporting for Food Stamp benefits.
•The State operates a fraud control program under which local, state, and federal officials may verify the information Ihave given. Verification will include confirmation through the Pennsylvania State Police Criminal Record Files, the Administrative Office of Pennsylvania Court files, and other records that are available.
•The state may obtain information about my circumstances from other persons or organizations, including computer matches and Immigration and Naturalization.
•The state and the Domestic Relations Section have the right to review all records of medical services paid for by medical assistance.
•Payment for medical services will be made directly tot he provider, not to me. This includes payments from Medicare.
•The law provides for automatic assignment tot he state of support rights for myself and others for whom I am accept- ing cash and/or medical assistance.
•If I receive cash benefits, all support including arrears will be paid to the state. If I receive medical benefits, medical support may be paid to the state. When benefits stop, arrears may be paid to the state to repay the amount of assis- tance granted. the amount of support retained by the state will not be more than the amount of cash assistance received and/or the amount paid under the medical assistance program.
Any household member found by a court or an administrative disqualification hearing of misrepresenting his identity or residence to receive multiple food stamps will be disquali- fied for 10 years.
FOOD STAMP WORK REQUIREMENTS/SANCTIONS - If you are physically and mental- ly fit, over 15 years of age and under 60 years of age, and not otherwise exempt, you may not refuse to register for employment; participate in an approved employment and training program unless you have good cause; accept employment unless you have good cause; provide sufficient information to your County Assistance Office about your employment status and job availability unless you have good cause or comply with workfare. Additionally, you must not voluntarily and without good cause quit your job or reduce the number of hours you work if, after the reduction, you are employed less than 30 hours per week.
CASH ASSISTANCE WORK REQUIREMENTS/SANCTIONS - A mandatory participant who fails to cooperate with the work or work-related activity requirement; participate in ETP; accept a bona fide offer of employment; or who terminates employment; reduces earnings or fails to apply for work; without good cause, is ineligible for cash assistance.
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To ensure the continued receipt of benefits like cash, medical, and food stamps without any interruptions, the PA 600R form, provided by the Commonwealth of Pennsylvania Department of Public Welfare, requires careful completion. It's a crucial step in the benefits review process, designed to reassess eligibility for ongoing support services. Here are systematic instructions to guide you through the form filling process smoothly.
By following these steps accurately, you can submit the PA 600R form confidently, ensuring that your eligibility for benefits is reviewed without any unnecessary delays.
What is the purpose of the PA 600R form?
The PA 600R form is used for reviewing an individual's eligibility for various benefits in Pennsylvania, including cash, medical, and food stamps assistance. It's a critical step in ensuring that those who need help continue to receive it without interruption. Applicants must fill out the form accurately and completely, sign it, and follow instructions for submission, which may involve bringing it to a county assistance office or mailing it for a telephone interview.
How can I submit the PA 600R form if I am unable to visit the county assistance office in person?
If a personal visit to the county assistance office is not feasible, the PA 600R form provides an option for a telephone interview. You should complete the form to the best of your ability, sign it, and mail it along with any requested verification documents to your caseworker. It's important to ensure that your contact information is current and accurate to facilitate this process.
Can someone help me fill out the PA 600R form?
Yes, if you need assistance completing the PA 600R form, you have several options. Another person you trust can help fill it out, or you can seek help directly from your county assistance office. Getting help is encouraged to ensure the form is filled out correctly, which is crucial for the review process of your eligibility for benefits.
What happens if I do not check ‘Yes’ or ‘No’ for the voter registration question on the PA 600R form?
If you do not select either ‘Yes’ or ‘No’ for the voter registration question, it is interpreted as your decision not to register to vote at this time. Your decision on voter registration will not affect your benefits in any way. However, if you wish to register to vote and meet the eligibility criteria, it’s important to respond to this question accordingly. Assistance is available through the county assistance office if you need help with the voter registration form.
Filling out the PA 600R form for benefits review under the Commonwealth of Pennsylvania Department of Public Welfare requires careful attention to detail. Mistakes in the application process can delay or affect the eligibility for cash, medical, and/or food stamps benefits. Here are five common mistakes people make:
In summary, thoroughness and accuracy are paramount when filling out the PA 600R form. Applicants are encouraged to seek help from their County Assistance Office if they have questions or need clarification during the application process.
When filling out or submitting the PA 600R form, which is an essential document for benefits review in Pennsylvania, there are several other forms and documents that individuals might also need to provide to ensure a thorough and accurate processing of their application. These documents are crucial for verifying information and aiding in the decision-making process regarding eligibility for cash, medical, and/or food stamps benefits.
Accurately completing the PA 600R form and providing these associated documents helps ensure that the application process goes smoothly. Gathering these materials ahead of time can save applicants time and reduce the need for follow-up, potentially leading to quicker determinations on eligibility and assistance levels.
The PA 600R form is similar to the Annual Recertification for Federal Programs (HUD Forms) used by the U.S. Department of Housing and Urban Development. Both forms serve the purpose of reassessing eligibility for benefits provided to individuals and families. They require detailed information about household composition, income, expenses, and any changes that have occurred since the last review. Completing these forms accurately ensures continued assistance without interruption, highlighting the need for up-to-date and thorough documentation of personal circumstances.
Another document akin to the PA 600R form is the Supplemental Nutrition Assistance Program (SNAP) Recertification form used across the United States to determine ongoing eligibility for food assistance benefits. Similar to the PA 600R, the SNAP recertification form asks for comprehensive information on household income, size, and expenses, alongside verification of any income changes. Both forms play a critical role in ensuring that support goes to those who are still eligible under the program's guidelines, requiring participants to report accurately and fully all pertinent details about their current situation.
Lastly, the PA 600R form shares similarities with the Health Insurance Marketplace's Annual Renewal and Change Form. This form is necessary for individuals and families that need to renew their health insurance coverage each year or report changes affecting their eligibility or premium. Like the PA 600R, this form emphasizes the importance of current information in determining eligibility and the correct level of benefits or coverage. It showcases the intersection of public assistance and healthcare policy, reinforcing the need for vigilance and accuracy in reporting household and financial changes.
When filling out the PA 600R form, a crucial step for maintaining eligibility for benefits in Pennsylvania, certain strategies should be embraced while others are avoided to ensure a smooth review process. Here's a guideline designed to navigate the complexities of this form.
When it comes to understanding the PA 600R form, it's vital to address common misconceptions that often circulate among individuals seeking benefits in Pennsylvania. This form is an essential element of the benefits review process for cash, medical, and food stamps assistance under the Commonwealth of Pennsylvania's Department of Public Welfare. Let’s clarify some of these misunderstandings to ensure eligible individuals can fully utilize the assistance available to them.
Misconception 1: Completing the PA 600R form guarantees immediate approval of benefits. It’s important to understand that the PA 600R form is part of a review process to determine continued eligibility for benefits. Completion and submission of the form is a necessary step, but it doesn’t automatically ensure approval. The information provided must be verified by your County Assistance Office to make a determination.
Misconception 2: The PA 600R form is only for renewing existing benefits. While one of the primary purposes of the PA 600R is to review the eligibility of existing benefit recipients, it also allows for the addition of new household members who may be eligible for benefits. This aspect is crucial for families whose size or circumstances have changed.
Misconception 3: Assistance from a caseworker is not necessary to complete the form. The form itself encourages individuals to seek help if needed. While many people can complete the form on their own, there is ample room for error or misunderstanding. Assistance from a caseworker or the County Assistance Office can provide clarity and ensure the accuracy of the information provided.
Misconception 4: Personal information is not secure once submitted. The confidentiality and security of applicant information are of utmost importance. The process of handling this form complies with state and federal regulations designed to protect personal information. Any concerns about privacy should be addressed with your caseworker.
Misconception 5: Voter registration is mandatory to receive benefits. The form includes an optional voter registration section, stressing that it's a voluntary action. Registering to vote or choosing not to register has no impact on the determination of benefits. This optional section is included to facilitate voter registration but is separate from the benefits eligibility process.
Clearing up these misconceptions about the PA 600R form can lead to a smoother process for individuals seeking assistance, ensuring that eligible recipients understand their rights, responsibilities, and the scope of the benefits review process. It's essential for applicants to communicate openly with their caseworkers, ask questions, and seek clarification when needed to fully navigate the benefits system effectively.
Filling out the PA 600R form is essential for individuals in Pennsylvania seeking to review their eligibility for benefits such as cash, medical, and/or food stamps. Here are nine key takeaways designed to make the process easier and ensure that applicants can navigate it with confidence:
By following these guidelines and ensuring all information provided on the PA 600R form is complete and accurate, applicants can navigate the benefits review process more smoothly, helping to secure the assistance they need without unnecessary delay.
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