Organization of Case File Materials
1. Place the following dividers on the left side of the case file, placing A atop B, B atop C, continuing through F, and place the forms/information/verifications under each divider as indicated below:
102A – Income (Earned and Unearned)
- DFS-103 Change Report, when income change reported
- DFS-105 Contribution Statement, when in-kind income or contribution
- DFS-106 Employer’s Statement
- DFS-107a-b Best Estimate of Earnings
- DFS-108a Income from Farm Operations Worksheet
- DFS-108b Self-Employment Worksheet
- DFS-111 Student Financial Assistance Verification/Worksheet
- DFS-303 Migrant Employer Verification Request
- DFS-401 Family Care/Kid Care A/B Worksheet
- DFS-605 IV-E Foster Care Worksheet
- DFS-606 Foster Care Budgeting Worksheet
- DFS-715 Income Verification from Employer, when not PRICE related
Wage stubs, business records from self-employment, income tax forms, award letters, TPQY’s, worksheets used to determine monthly income eligibility (DFS-401, 402, 412, 413, 414, 415), interface screens showing earned and unearned income, EPICS income work screens.
Other sources to verify: CS payments, Military allotments, Pensions, UIB, Worker’s Comp, VA, railroad, Civil service, retirement, Rental income, Social security, Dividends, interest, Money from friends/relatives, Gifts, loans, Mineral lease, royalty, Severance or disability pay. Sick pay
102B – Resources
- DFS-103 Change Report, when resource change reported
- DFS-115a-b Resource Verification
- DFS-404 Spousal Resource Assessment
- DFS-406 Health and Life Insurance Verification
- REAS EPICS Resource Assessment screen
Property/bank checks, title(s), deeds, vehicle registration or RIS screen prints (including boats, airplanes, campers, off-road vehicles, motorcycles, trailers).
Other verifications for: Life insurance, Burial plots/plans, Stocks, life estates, Savings bonds, CD’s, IRA’s, Keogh’s, Pension/retirement plans, Trust funds, Mineral rights, Notes or contracts of value, Tools, equipment
102C – Expenses and Deductions
- DFS-103 Change Report, when address, expense, deduction change reported
- DFS-105 Contribution Statement, when relating to living arrangements
- DFS-300 Application for Allowable Deductions
Rent receipts, house/mobile home payments, lease agreements, taxes, homeowners insurance, space rental, subsidized housing, utilities (gas, electric, propane, heating oil, coal, wood), garbage/trash/water/sewer, telephone, deposits, utility installation, day are expenditures, medical expenditures, child support/alimony paid out.
102D – Performance Requirements/E &T/Education
- DFS-110 Statement of Incapacity
- DFS-301 Work Registration Form
- DFS-500 Individual Responsibility Certificate of Understanding (IRCU)
- DFS-501 Appointment Form
- DFS-561 Assessment Form
- DFS-562a Request for Work Activity Expenditure
- DFS-562b Work Activity Expenditure Record
- DFS-563 Status Change Report
- DFS-564a Work Experience Training Agreement
- DFS-565 Labor Market Assessment/Agreement
- DFS-566 Weekly Work Search Activity Record
- DFS-567 Referral/Request for Information
- DFS-568 Individual Responsibility Plan (IRP)
Work related noncompliance information, all other information relating to work program requirements, education and E&T.
102E – Child/Day Care
- DFS-200 Child Care Authorization
- DFS-201 Bill for Child Care Services
- DFS-202 Notice to Child Care Providers
- DFS-203a Registration Form for Licensed Child Care Providers
- DFS-203b Registration Form for Unlicensed Child Care Providers
- DFS-204 Provider Assessment Form
- DFS-205 Verification of Presumptive Eligibility
- WOLFS109 Payee Information Form
Work/class/counseling schedules, child care checklist, print screens, authorizations and billings.
102F – Child Support
- DFS 543 Report to Child Support Enforcement
- DFS 545/546 Child Support Cooperation Notice/Good Cause Claim
Medical support information, continued absence documentation, noncompliance information, evidence to substantiate good cause, E-mail of approval or denial of good cause, information from the child support authority/services.
2. Place the following dividers on the right side of the case file, placing G atop H, H atop I, continuing through L:
102G – Narrative/Notification
- DFS-603 Foster Care Narrative
- DFS-411 Notice to LSC Facility
Narrative/documentation, correspondence, when not related to a specific tab, E-mail correspondence.
102H – Applications/Recerts/Reviews
- DFS-101 Before You Apply
- DFS-100 Application for Benefits/Review Form
- DFS-103 Change Report forms, when not related to specific tab
- DFS-400 Presumptive Eligibility for Pregnant Women
- DFS-405 Facility Assessment Offer and Estate Recovery Information, when related to facility assessment
- DFS-408 HICMA and SSI Related Checklist
- DFS-409 HICMA Second Party Review
- DFS-602 Foster Care Periodic Review
- DFS-604 EA Supervisory IV-E Review Form
- DFS-607 Subsidized Adoption Review Form
- SS-501 Social Worker Transmittal to Benefit Specialist
SAV, STAR and QA review forms with no overpayment
102I – Initial/Permanent Verifications
- HCF-WHIPP Health Insurance Verification
- LT 101 Medical Necessity Assessment for Long Term Care
- LT MR 104 Level of Care Criteria for ICF/MR
- LT ABI 105 Level of Care Criteria for ICF/MR (for Acquired Brain Injury)
- SS-43 Adoption Assistance Agreement
Divorce decree(s), social security cards(s), marriage license(s), birth certificate(s), proof of citizenship, drivers license(s), adoption paper(s), photo ID’s, death certificate, Medicare card(s), health insurance information, proof of application for SSN.
102J – Recovery/QC Findings/Admin Hearings
- DFS-703 First Notice of Overpayment (non-EPICS programs)
- DFS-705 Notice of Disqualification or Judgment
- DFS-715 Income Verification from Employer, when PRICE related
- DFS-719 Referral for Fraud Investigation
- DFS-760 Overpayment Case Information Document
- DFS-8401 QC Review Information
- DFS-8402 QC Error Citation
QC discrepancy/deficiency reports, copies of PAAL/interface screens, as appropriate, all information/correspondence documenting overpayment(s).
102K – Miscellaneous
- DFS-112 Report of Interstate Move
- DFS-304 FS Replacement Questionnaire
- DFS-305 Card Authorization Form
- DFS-306 Affidavit for Lost, Destroyed or Stolen PayWest Card
- DFS-416 Give One Day Eye Care Program
- DFS-417 Outstationing Log
- CHS-5 CHS Medical Purchase/Special Travel/Per Diem Authorization
- HCF-PC-T001 Administrative Transportation Log
- HCF-PC-T002 Medical Travel Authorization
No # Dental, Vision, Hearing Medical Referral Form E-Form(s) Relating to BPU
Other information/forms not listed elsewhere.
3. Use the divider with the blank tab for material not applicable to a specific divider or as established/ directed by the DFS-FO.
102L – Blank Tab
