MR #19.06: New Form to Use for Client's Proof of Benefits Received

Illinois Department of Human Services logo

04/03/19

Summary

Many customers come into the Family Community Resource Center (FCRC) to request proof of the benefits they are receiving to provide as verification to another agency or governmental department. This manual release is to provide a uniform procedure for all FCRCs to follow when assisting customers who are requesting proof of their program benefits. All FCRCs should complete the newly created Proof of Receipt of Program Benefits (Form 3711) for consistency and to ensure that the appropriate information is provided regarding the customer's eligibility for benefits.

  • This manual release is to provide a uniform procedure for all FCRCs across the State to follow when assisting customers who are requesting proof of their eligibility for program benefits. All FCRCs should complete the newly created Proof of Receipt of Program Benefits (Form 3711) when assisting customers who are requesting proof of their benefits. Form 3711 is located in the OneNet Forms Library.
  • The FCRC should complete Form 3711 for any customer requesting proof of their benefits. When a customer asks the FCRC to give them proof of their benefits, FCRC staff should assist in providing the information by completing Form 3711 in its entirety and with the most recent information.
  • In some instances, a customer may qualify for additional services with an outside entity if they can show proof that they are eligible for our programs. 
    • Example: A customer who is applying for a fee waiver from the Department of Homeland Security - U. S. Citizenship and Immigration Services (USCIS) may be eligible for a waiver of fees related to various applications and petitions processed by USCIS. The waiver is requested using USCIS Form I-912. One way that a customer can justify the fee waiver request is by providing proof that they and their family members are receiving Medicaid, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF) or Aid to the Aged, Blind, or Disabled (AABD).

Completion of Form 3711

  1. When a customer asks the FCRC for verification of their benefits, find out from the customer the names of all persons who should be included on Proof of Receipt of Program Benefits (Form 3711) (pdf). Use the Integrated Eligibility System (IES) to verify eligibility for each individual. Do not give copies of IES screens to the customer to use as their proof of benefits. 
  2. Complete Proof of Receipt of Program Benefits (Form 3711) in the following sections:
    1. Full name of the person;
    2. Enter (Yes) or (No) for the applicable program the person is receiving. Do not leave blank; and
    3. The current benefit receipt month; and
    4. Date benefit is approved; and
    5. Date benefit ends (or must be renewed).
  3. The IDHS employee completing Form 3711 should sign and complete the name and address in the FCRC section. Affix the Family Community Resource Center stamp to the form. 
  4. Upload a copy of the Form 3711 to the customer's electronic case file in IES.

Bureau of Customer Support and Services

Form 2160, Verification of Public Assistance Income is a new form used to verify income for the Illinois Housing Authority. This form should only be used by the DHS helpline staff.

Manual Revisions 

PM 01-01-04
WAG 01-01-04

[signed copy on file]

Grace B. Hou

Secretary Designate, Illinois Department of Human Services

Forms referenced:

Form 3711

Form I-912