Form DWS-WDD612 "TANF Contracted Services Family Composition" - Utah

What Is Form DWS-WDD612?

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

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Utah Department of Workforce 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 DWS-WDD612 by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-WDD612 "TANF Contracted Services Family Composition" - Utah

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DWS-WDD 612
State of Utah
Rev. 02/2018
Department of Workforce Services
TANF CONTRACTED SERVICES
FAMILY COMPOSITION
Organization:
TANF service(s) being provided:
Name of client receiving service(s):
DWS case number (if applicable):
Instructions: There must be a dependent child under age 18 living in the home where the client has a plan to
reunite or re-engage with. List the names of the dependents and their adult caretakers below:
Name of parent or relative caretaker
DWS case number (if applicable)
Address of parent or relative caretaker
City, State, Zip Code
List dependent children’s names:
Dates of birth (MM/DD/YYYY):
Describe re-unification or re-engagement plan. Provide details and anticipated completion date.
Supporting documentation must be present in client’s case file.
I attest the information I have provided above is accurate.
Client signature
Date
I give consent for the client to re-unite and/or re-engage with the child(ren) listed above, upon completion of the
client’s proposed plan.
Parent or relative caretaker signature
Date
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
DWS-WDD 612
State of Utah
Rev. 02/2018
Department of Workforce Services
TANF CONTRACTED SERVICES
FAMILY COMPOSITION
Organization:
TANF service(s) being provided:
Name of client receiving service(s):
DWS case number (if applicable):
Instructions: There must be a dependent child under age 18 living in the home where the client has a plan to
reunite or re-engage with. List the names of the dependents and their adult caretakers below:
Name of parent or relative caretaker
DWS case number (if applicable)
Address of parent or relative caretaker
City, State, Zip Code
List dependent children’s names:
Dates of birth (MM/DD/YYYY):
Describe re-unification or re-engagement plan. Provide details and anticipated completion date.
Supporting documentation must be present in client’s case file.
I attest the information I have provided above is accurate.
Client signature
Date
I give consent for the client to re-unite and/or re-engage with the child(ren) listed above, upon completion of the
client’s proposed plan.
Parent or relative caretaker signature
Date
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.