WAG 02-06-01-f: Forms and Referrals

(EW) Obtain the applicant's signature, as needed, on any forms required to establish eligibility.

Review Form 2378B and Form 2378H for completeness and required signatures. If an application form from a hospital or nursing home (Form 2378H) is incomplete, return it to them.

  • For long term care applicants, if Report on Resident of Private Long Term Care Facility (HFS Form 26) is incomplete or a question(s) has not been answered, promptly return the form to the facility with instructions for completion.
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  • Complete and forward Non IV-D Support Referral (Form 2355) to the Field Recovery Unit. Do not complete and send Form 2355 for parents of a child age 18, 19, or 20 if the child does not live with the parent. This includes a child who lives apart from the parents because the child resides in a medical facility. However, be sure to check the box on the form if the applicant is under age 18 and is a client of DCFS or DHS (see WAG 09-02-04).
  • If the applicant expects a change in circumstances which may affect eligibility or the amount of assistance, attach a Notice of Anticipated Change (Form 2122) to the front of the case record when it is approved.
  • Complete Part A of VA Outreach Report Sheet (Form 2881). See WAG 09-03-01-e when referring a person to IDVA to apply for Aid and Attendance.

When you need the applicant's written consent for release of information, use Consent to Release of Information (Form 34) if there is no release statement on the request form. Use Authorization to Release Medical Records (Form 4701H) to get medical information.

Complete the following forms and referrals as required:

1. Control Cards

Use CAF Folio (Form 2389) to record and control the intake process. Also use the Application Pending lists to control the process.

2. Information/Verification Requests

Use Form 267, Form 267E, or Form 267F for All Kids applications, to tell the applicant of verifications and information needed to determine eligibility. Keep a copy in the case record.

Use Form 267D to tell the client that information is requested when the absent parent is not a legal parent.

Copies, carbon copies, and faxes are acceptable forms of verification unless there is evidence that the original or the copy was changed. If there are signs of alteration, ask for other verification.

(AIS) Upon request, generates a Bank Inquiry (Form 46CF), a Request for Employment Verification (Form 266CF), and a Verification of School Attendance (Form 541CF).


3. Intake Worksheets

AIS calculates income for TANF cash, FamilyCare Assist, and All Kids cases. Complete a TANF Cash Computation Form (Form 2383C) and a Supplement to Form 2383C - TANF Cash Computation (Form 2383B), or a TANF MANG Computation Sheet (Form 2383A) when AIS is down or inaccessible or when a budget calculation needs to be made for an RRA case.

4. SMIB Referrals

If the applicant is potentially eligible for SMIB, refer the person to the SSA to apply (see PM 22-07-02).

5. Child Support Order and Support Payments

Contact the FRC to request an expedited appointment with DCSE to restore assistance on a case that was canceled for not cooperating in the child support enforcement process and now wants to cooperate.

Do not restore assistance to a caretaker relative who refused to cooperate in the child support enforcement process until they agree to cooperate. See WAG 24-04-08 to restore a caretaker relative who agrees to cooperate.

If the caretaker relative does not agree to cooperate, see PM 24-04-04.

Complete AIS screen 3G to report a child support order or voluntary support when:

  • a child with an absent parent is included in an application for TANF cash, All Kids Assist, or AABD(D) Medical;
  • support has been received from an absent parent within 60 days of the application date; and
  • the support is not ordered payable to HFS.

A set of forms is printed, including print 3G, when F8 is entered on screen 3N in an FCRC which uses the IV-A/IV-D consolidated intake interview.

Enter F12 to print the final CAF, which includes print 3G, in an FCRC that does not use the IV-A/IV-D consolidated intake interview.

Print the first and last name of the child for each line entry right on print 3G. Make a copy of print 3G and forward the original to the DCSE.

File the copy of the CAF print in the responsible relative section of the case record.

For non IV-D support referrals, complete and forward Non IV-D Support Referral (Form 2355) to the Field Recovery Unit. Be sure to check the box on the form if the client is also a client of DCFS or is receiving help from Mental Health Development or Disability Services from DHS (see WAG 09-02-04-a).

When a case has a dependent child for whom there is an absent parent and the absent parent is coded with 02, 19, 20, 21, 22, or 24 in Form 552 Item 63, Status of Parent, the system automatically refers the case to DCSE. The mother/father status code is a required entry for all TANF, FamilyCare Assist, All Kids Assist, and Moms and Babies cases.

Enter the caretaker relative's name in Item 8 of Form 552 to assign an RPY if a case with a child under age 19 has no adult in it.

Enter code 19, 20, 21, 22, or 24 in Form 552 Item 63 for the absent responsible relative to refer a child to DCSE who has never been included in the assistance unit (e.g., a newborn).

6. Good Cause for Refusal to Cooperate

For TANF cash, FamilyCare Assist, and All Kids Assist, have the adult applicant(s) read and sign 2 copies of Notice Concerning Good Cause for Refusal To Cooperate (Form 1260A) (see PM 01-02-00).

Sign Form 1260A and provide the applicant with a copy of the form.

If the client refuses to sign the form, make a notation on the signature line client refused to sign. Date the form and file it in the case record.

For mail-in applications (Form 2378H, Form 2378KC, or Form 2378MC), mail a copy of Form 1260A to the applicant. Do not require that the client sign Form 1260A.

7. Third Party Resource

Review Form 267-TPL and identify all third party resources. Only one parent needs to sign the form if 2 parents are in the home. If the applicant failed to complete Form 267-TPL, issue another form. Do not require that Form 267TPL be signed for Form 2378H, Form 2378KC, or Form 2378MC applications.

Review HIPP inquiry questions on AIS. If a family member has a high cost medical condition and available health insurance, help the applicant complete Health Insurance Premium Payment (HIPP) Referral (Form 3459B).

Complete Health Insurance Report (Form 1442/1442CF) for all third party resources (see WAG 26-03-01-a).

When a person reapplies, and during the eligibility interview indicates there is new health insurance coverage to report since the time the case was canceled, complete the TPL screens in AIS for each health insurance policy. New coverage to report includes benefits provided as a result of employment, or a new or modified support order which adds or changes TPL coverage.

When an applicant cannot provide complete health insurance information, enter at least the policyholder's name, who is covered, and their relationship to policyholder. Obtain health insurance information and complete TPL screens before approving the case.

(AIS) Generates Form 1442CF when the case is approved. Two copies of the form print on the Family Community Resource Center printer for each health insurance policy reported for each person in the assistance unit.

(EW) Send one copy of Form 1442CF for each case to the BOC, TPL Section, and file the other in the case record. If the form is destroyed or cannot be located, print another copy.

(FRC) Reviews, signs, and forwards Form 1442CF to BOC with the TPL transmittal memo on a weekly basis.

(EW) Attempt to obtain missing information before sending an incomplete form to the FRC. If the client does not give sufficient information to complete Form 1442CF and you are unable to obtain it by phone or mail, indicate efforts in the Remarks Section. See WAG 26-03-01-a, Instructions for Completing Form 1442/1442CF-Referring a TPL Resource.

Attach a copy of the client's insurance identification card or other verification to Form 1442/1442CF, if available.

Code TPL for the current month in AIS or in Item 79 of Form 552 only after completing for all affected applicants:

  • Form 1442CF,
  • TPL clearance, or
  • TPL segment of PF8.

8. Social Security Number Application

Refer each person who does not have a Social Security Number to the nearest Social Security District Office via completion of Requirement to Apply for a Social Security Number Card (Form 3168).

Complete Form 267, Form 267E, Form 267F, or Form 1721 to request an SSA 5028 as confirmation from the SSA District Office that an application for an SSN was made. EW Inform the client that applying for an SSN is a condition of eligibility for each person for whom cash or medical assistance is requested.

(Applicant) Upon request, reports to local Social Security District Office to apply for a social security number.