Form 168 "School Verification Form" - Delaware

What Is Form 168?

This is a legal form that was released by the Delaware Health and Social Services - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2010;
  • The latest edition provided by the Delaware Health and Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 168 by clicking the link below or browse more documents and templates provided by the Delaware Health and Social Services.

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Download Form 168 "School Verification Form" - Delaware

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DCIS # ___________________
RETURN TO:
_______________________________
PHONE: _____________________________
_______________________________
CASE NAME: _________________________
TO:
______________________________________
ADDRESS: ____________________________
______________________________________
_______________________________
______________________________________
DCIS # _______________________________
Dear Sirs:
Verification of school enrollment and attendance is needed to establish eligibility for Public Assistance. Please
give the information checked below for the following student(s). We thank you for you cooperation.
Sincerely Yours,
___________________________________________
DSS Worker
Pool Code
STUDENT: ______________________________
PARENT OR GUARDIAN
D.O.B.:___________________________
_______ Same as case name (above)
GRADE: _________________________
_______ Different (List Parent/Guardian)
ADDRESS: Same as above _________
______________________________________
Different: (List Address) ____________
________________________________
If part-time student, how many hours a week does he/she attend? _______________________________
Is this student’s attendance satisfactory? _________Yes
__________No
If the student is over 18, what is the expected date of completion or graduation? ____________________
Other ___________________________________ (e.g. student transferred, dropped out, etc.)
STUDENT: ______________________________
PARENT OR GUARDIAN
D.O.B.:___________________________
_______ Same as case name (above)
GRADE: _________________________
_______ Different (List Parent/Guardian)
ADDRESS: Same as above _________
______________________________________
Different: (List Address) ____________
________________________________
If part-time student, how many hours a week does he/she attend? _______________________________
Is this student’s attendance satisfactory? _________Yes
__________No
If the student is over 18, what is the expected date of completion or graduation? ____________________
Other ___________________________________ (e.g. student transferred, dropped out, etc.)
AUTHORIZED SIGNATURE: _______________________________
DATE: __________________________
TITLE: ________________________________
TELEPHONE: ________________________________
Form 168 (Rev. 11/2010)
White: Return to DSS
Document No. 350701-90-08-42
Yellow: Record for School (Return to DSS if student’s status changes during the current school year
Pink: File
DCIS # ___________________
RETURN TO:
_______________________________
PHONE: _____________________________
_______________________________
CASE NAME: _________________________
TO:
______________________________________
ADDRESS: ____________________________
______________________________________
_______________________________
______________________________________
DCIS # _______________________________
Dear Sirs:
Verification of school enrollment and attendance is needed to establish eligibility for Public Assistance. Please
give the information checked below for the following student(s). We thank you for you cooperation.
Sincerely Yours,
___________________________________________
DSS Worker
Pool Code
STUDENT: ______________________________
PARENT OR GUARDIAN
D.O.B.:___________________________
_______ Same as case name (above)
GRADE: _________________________
_______ Different (List Parent/Guardian)
ADDRESS: Same as above _________
______________________________________
Different: (List Address) ____________
________________________________
If part-time student, how many hours a week does he/she attend? _______________________________
Is this student’s attendance satisfactory? _________Yes
__________No
If the student is over 18, what is the expected date of completion or graduation? ____________________
Other ___________________________________ (e.g. student transferred, dropped out, etc.)
STUDENT: ______________________________
PARENT OR GUARDIAN
D.O.B.:___________________________
_______ Same as case name (above)
GRADE: _________________________
_______ Different (List Parent/Guardian)
ADDRESS: Same as above _________
______________________________________
Different: (List Address) ____________
________________________________
If part-time student, how many hours a week does he/she attend? _______________________________
Is this student’s attendance satisfactory? _________Yes
__________No
If the student is over 18, what is the expected date of completion or graduation? ____________________
Other ___________________________________ (e.g. student transferred, dropped out, etc.)
AUTHORIZED SIGNATURE: _______________________________
DATE: __________________________
TITLE: ________________________________
TELEPHONE: ________________________________
Form 168 (Rev. 11/2010)
White: Return to DSS
Document No. 350701-90-08-42
Yellow: Record for School (Return to DSS if student’s status changes during the current school year
Pink: File