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|[pic] |Temporary Assistance for Domestic Violence Survivors (TA-DVS) |

| |Eligibility and Benefit Calculation Worksheet |

|Step 1: Determine eligibility for the program: |

|( |Find the TANF countable income standard for the number of persons in the TA-DVS household: |$ |      | |

|( |Fill in the chart below: (TANF grants are not counted in TA-DVS initial month eligibility calculations) |

| |Source of income ( |A. NET wages |B. Unemployment |C. SSI |D. Child support |E. Cash on hand |F. Other |

| | | |benefits | | | | |

| |Amount available in budget month | $ |      |$ |

|2 |Amount controlled by abuser * |- $ |      | |

|3 |Amount used to address |- $ |      | |

| |safety issues** | | | |

|4 |Amount client no longer can access *** |- $ |      | |

|Subtract rows 2-4 from row 1 to get money available for current |= $ |0.0[pic]0.00 | |

|emergency needs | | | |

|Subtract living expenses not yet paid for budget month |-$ |0[pic]0.00 |Rent/ mortgage |

|Step 2: Determine income available over the 90 day eligibility period |

| |

|Source of income ( |Net wages |SSI |Child support |TANF grant |Other |A. Monthly total |

|Expected month 1 |$       |$       | $       |$       |$       |$ 0[pic]0.00 |

|Expected month 2 |$       |$       |$       |$       |$       |$ 0[pic]0.00 |

|Expected month 3 |$       |$       |$       |$       |$       |$ 0[pic]0.00 |

|B. Monthly expenses |Rent/ mortgage |Utilities |Phone |Transportation costs |Child care |Medical |Food |Other |Total |

| |$       |$       |$       |$       |$       |$       |$       |$       |$ 0[pic]0.00 |

|C. Client’s income minus (A minus B) |Month 1: $ 0.0[pic]0.00 |Adjustments:       |Subtract any income unavailable to the client because it is controlled by the |

|living expenses | | |abuser or any income the client used or needs to remain free from the |

| | | |violence. |

| |Month 2: $ 0.0[pic]0.00 | | |

| |Month 3: $ 0.0[pic]0.00 | | |

• This calculation (C.) can be used to help establish what financial resources the client has available to help meet their current or future needs, including housing needs.

• TA-DVS funds are not intended to meet on-going or basic needs and should be used to address specific emergent or stabilization needs over the 90 day eligibility period and should not exceed a total of $1200.00 over the eligibility period.

• Timeliness is critical in supporting the survivor to stay free from domestic violence and a TA-DVS payment should not be delayed pending receipt of income when safety is at risk.

• TA-DVS payments are made either using the dual payee process or vendor pay process unless doing so would put the client at greater risk of domestic violence. If the vendor/dual payee process can’t be used narrate the reason why in TRACS.

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