Form DWS-ESD/WDD 300 "TANF Needy Family Eligibility Form" - Utah

What Is Form DWS-ESD/WDD 300?

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 July 1, 2019;
  • 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 printable version of Form DWS-ESD/WDD 300 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-ESD/WDD 300 "TANF Needy Family Eligibility Form" - Utah

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DWS-ESD/WDD
State of Utah
Department of Workforce Services
300 Rev. 07/2019
TANF NEEDY FAMILY ELIGIBILITY FORM
Case/PID # if applicable)
Section 1: Household information. There must be a dependent child under age 18 living in the
home. A Social Security number is a condition of eligibility for assistance required by section 1137
of the Social Security Act. Services will not be delayed or discontinued pending the issuance or
verification of a Social Security number, if the applicant has documented application for one. Social
Security numbers must be provided for all individuals included in the TANF Needy Family
household size.
For more information please access the TANF contractor website at
http://jobs.utah.gov/services/tevs/tanfcontract.html
PLEASE USE A BLACK BALL POINT PEN TO COMPLETE FORM
Parent or relative caretaker name (first, middle initial, last)
Social Security number
Utah resident?
Yes
No
Address
Gender:
Female
Male
Alien registration number:
Date of birth (MM/DD/YYYY)
Date of Entry:
Spouse or relative caretaker name (first, middle initial, last)
Social Security number
Date of Birth (MM/DD/YYYY)
Utah resident?
Yes
No
Gender:
Female
Male
Date of Entry
Alien registration number:
Dependent Child Name (First, M.I., Last)
Social Security #
Alien Registration
number:
Date of birth (MM/DD/YYYY)
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Alien Registration
number:
Date of birth (MM/DD/YYYY)
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Date of birth (MM/DD/YYYY)
Alien Registration
number:
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Date of birth (MM/DD/YYYY)
Alien Registration
number:
Gender:
Female
Male
DWS-ESD/WDD
State of Utah
Department of Workforce Services
300 Rev. 07/2019
TANF NEEDY FAMILY ELIGIBILITY FORM
Case/PID # if applicable)
Section 1: Household information. There must be a dependent child under age 18 living in the
home. A Social Security number is a condition of eligibility for assistance required by section 1137
of the Social Security Act. Services will not be delayed or discontinued pending the issuance or
verification of a Social Security number, if the applicant has documented application for one. Social
Security numbers must be provided for all individuals included in the TANF Needy Family
household size.
For more information please access the TANF contractor website at
http://jobs.utah.gov/services/tevs/tanfcontract.html
PLEASE USE A BLACK BALL POINT PEN TO COMPLETE FORM
Parent or relative caretaker name (first, middle initial, last)
Social Security number
Utah resident?
Yes
No
Address
Gender:
Female
Male
Alien registration number:
Date of birth (MM/DD/YYYY)
Date of Entry:
Spouse or relative caretaker name (first, middle initial, last)
Social Security number
Date of Birth (MM/DD/YYYY)
Utah resident?
Yes
No
Gender:
Female
Male
Date of Entry
Alien registration number:
Dependent Child Name (First, M.I., Last)
Social Security #
Alien Registration
number:
Date of birth (MM/DD/YYYY)
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Alien Registration
number:
Date of birth (MM/DD/YYYY)
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Date of birth (MM/DD/YYYY)
Alien Registration
number:
Gender:
Female
Male
Dependent Child Name (First, M.I., Last)
Social Security #
Date of birth (MM/DD/YYYY)
Alien Registration
number:
Gender:
Female
Male
Section 2: Mark all services the customer is receiving. If any of these services are
marked, the family may meet the income eligibility requirement.
Documentation must be provided for all services marked. If no services are
marked move to Section 3.
CHIP (Children’s Health Insurance
Refugee Cash Assistance
Program) Plan A, B, or C
Family Employment Program (FEP)
Any of the following Family Medicaid
Programs:
Family Employment Program (FEP)
Child Medicaid, 12 Month Transitional
Diversion
Medicaid, Medically Needy Family,
Medically Needy Child, Pregnant
TANF (Temporary Assistance for
Woman or Medically Needy Pregnant
Needy Families) Non-FEP Training
Women
Women, Infant & Children (WIC) Food
Food Stamps
& Nutrition Service
Section 3: Income Guidelines. All parent or relative caretaker income is counted even if the parent or
relative caretaker is not eligible to be included in the household size.
Does the family meet the income requirement of the contract or service being provided?
Yes
No
Refer to Policy, Charts and Tables, Table 13 – Income Guidelines:
https://jobs.utah.gov/infosource/EmploymentBusinessManual/700_Eligibility/726_Income_Guidelines__TANF_Needy_Family
_-_Contracted_Services.htm
Monthly Gross Income of Parent(s) or Relative Caretaker(s) $
(Refer to Policy at above web address, Section 720-5, Sources of Includable and Excludable Income)
*Note: Use prior one full month of gross income and provide documentation of that income in case file.
I attest the information I have provided above is accurate.
Applicant Signature
Date
I attest the information provided by the customer is accurate to the best of my knowledge.
Contractor Signature
Date
Note: If any required information is incomplete or incorrect, the customer is not eligible for TANF Needy Family
funding.
If you do not agree with the decisions made regarding your case, you may request a Fair Hearing with an
impartial Hearing Officer verbally or in writing, by contacting either your contract service provider, or contacting
the Department of Workforce Services at 1-877-837-3247 or
https://jobs.utah.gov/appeals/pa/filingpublic.html
Contractor will enter required customer information into the TANF Eligibility Verification System (TEVS) at
least weekly, using the Form
300. Access the TEVS website
at:
http://jobs.utah.gov/jsp/tevs/
Form 300 information has been entered into TEVS for all customers with Social Security numbers.
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-ESD/WDD 300
Rev. 12/2014
INSTRUCTIONS FOR FORM 300
TANF Needy Family Eligibility Form
Purpose:
Form 300 is to be completed by all contractors who determine eligibility for services
they provide to TANF Needy Families. Documentation substantiating eligibility must
be present in the file for each family member included in the TANF Needy Family
household. Attach an additional Form 300 if needed for more than four dependent
children.
Preparation: Contracts must clearly state any other eligibility factors and documentation required
in order for the family to receive the service.
Case/PID may not apply for families not receiving DWS services.
Section 1: Families must have at least one US citizen or eligible alien in the TANF Needy Family
household to be eligible for TANF funded services. A household unit includes eligible parents or
relative caretaker(s) and their eligible dependent children under the age of 18 living in the home.
Documentation of citizenship or immigration status and relationship for all parents or relative
caretakers and their dependent children included in the TANF Needy Family household on Form
300 must be present in the case file. Refer to Table 9 for acceptable documentation.
Only enter eligible family members’ information on Form 300.
The family must declare they are or intend to be a resident of Utah.
Skip to Section 3 if customer does not currently receive any of the services listed in Section 2
Section 2: Mark services the customer is receiving. Acceptable verification includes
current letters or notices showing current eligibility status. All services marked must have
documentation of receiving those services included in the case file.
Section 3: Complete Section 3 if customer is not receiving any services listed in Section 2, showing the
Gross Monthly Income from the previous one full month. All income is counted. Acceptable
verification includes a statement from the employer, copies of check stubs, or other
documentation of previous one full month’s income. Refer to Table 13 for income guidelines.
The contractor will enter required TANF Needy Family information into TEVS. A DWS employee will retrieve
the information from TEVS and complete the required eShare query for the household. The contractor will
be notified if additional information from the customer is required or if a family member is no longer eligible
for the TANF Needy Family service. Refer to procedure, TANF Needy Family - Using the TANF Eligibility
Verification System (TEVS) for Contracted Service.
The contractor will mark the check box at the bottom of Form 300 when required TANF Needy Family
information has been entered into TEVS.
Applicant’s Signature: The customer must sign indicating the information given is correct.
Signatures: The contractor who is determining eligibility must sign and date the form.
Distribution: Original filed in the case record
Retention: Three (3) years
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