APPENDIX C-3
CHECKLIST FOR CASE ACTIONS (cont.)
The following sections provide checklists of common forms and actions that need to be completed for specific case circumstances such as taking a TANF application, completing a FS recertification or adding a newborn to a group.
VI. DC HEALTHY FAMILIES MEDICAID APPLICATION
VI-1: Forms that must be completed or given to applicant:
___DC Healthy Families Application
___1288A to Be Completed by Worker (If Applicable)
___1052 Record of Case Action to Be Completed by Worker
___Checklist to Be Given/Mailed to Customer, If Applicable
VI-2: Information to Collect from Applicant:
___Residency Verification
___SSN Verification
___Child Care Expense Verification
___Earnings Verification
___Medical Bills (Current & Retroactive Three Months)
VI-3: Actions to Be Taken If Applicant Applies at the Service Center:
___Discuss Child Support Requirement and Sanction, If Applicable
VII. SPEND-DOWN
These forms are used by spend-down SSRs only. Spend-Down cases are processed in the IMA Spend-Down Unit.
Forms that must be completed or given to Applicant/Recipients:
___1-2140 Spend-Down Tracking Form
___1052 Record of Case Action
___1692 Countable Medical Expenses
___1693 Spend-down Worksheet
VIII. MEDICAID RECERTIFICAITON
The Medicaid recertification form is mailed in for non-categorically eligible Medicaid cases.
___1209 Recertification for Medical Assistance
___1210 Recertification Work Sheet, If Applicable
___Required Verification
___1052 Record of Case Action
IX. ADDING A PERSON TO THE GROUP
IX-1: Forms that must be completed or given to applicant:
___1288 Notice of Child Support (If Applicable)
___IV-D Partnership Agreement (If Applicable)
___107 Verification of Household Composition
___CAD Addendum Form For New Person
___1049 Verification of Vital Event (If a Birth Certificate Is Needed)
___1549 School Form (If Applicable)
___Work Referral (If Applicable)
IX-2: Information to collect from customer:
___Income Verification
___Resource Verification (If Applicable)
___Living With Verification (If Applicable)
___Social Security Administration Receipt or SSN Card
___Verification of Age And Relationship (If Needed)
IX-3: Actions to be taken:
___If Adding Parent to TANF Case, Redetermine If Deprivation Exists
___If Adding a Child to TANF Case, Determine That Deprivation Exists for That Child
___Make Appropriate Notations on 1052
X. CHANGE IN ADDRESS THAT LEADS TO THE CASE BEING TRANSFERRED TO A DIFFERENT UNIT
OR CENTER
X-1: Forms that must be completed:
___Voter Registration Certification
___Voter Registration (If Applicable)
___1549 Verification of School Attendance (If Applicable)
___1052 Record of Case Action
X-2: Information to collect from recipient/customer:
___New Address Verification
___New Shelter Cost Verification (If Food Stamp Case)
X-3: Actions that must have been taken prior to transfer:
___Process Overpayment (If Applicable)
___Conduct an Eligibility Review If the TANF Case Has Not Been Reviewed Within the Last 6 Months
___Check that Recertification Notices for Food Stamps or Medicaid have not been issued. Case may
not be transferred if Recertification Notices have been issued.
___Verify and Update Shelter Cost If Receiving FS
___Issue New Change Report Form If Receiving FS
___Complete Change of Caseworker Notice
___Check Alerts Before Transfer
___Check Interfaces Before Transfer
___Request Investigation (If Expenses Exceed Income)
XI. CLOSING A TANF CASE
Actions to be taken:
___Include Copies of CAP 1 and CAP 2 Screens in Case Record
___Update 1052 Record of Case Action
___Include AFED, FSED, MEAE, ARED and Screens in Case Record
___Redetermine Medicaid Eligibility and Enter New Program Code (If Applicable)
___Continue Food Stamp Benefits (If Eligible)
___Complete Overpayment Packet (If Applicable)
___Complete 886 Information of Exchange to Child Support
___Issue Notice of Adverse Action, Giving 15 Days Adequate and Timely Notice
XII. ADDING OR CHANGING A PAYEE
In the event that the new payee was not a member of the original unit the following procedures should be followed.
XII-1: Forms that must be completed:
___Generic Application and All Applicable Forms. Payee must Fill out All Generic Application Forms
XII-2: Information to collect from recipient:
___See TANF Application Checklist
XII-3: Actions to be taken:
___Close Prior TANF Case
___Redetermine Eligibility
___Update 1052 Record of Case Action
___Re-verify Relationship (If Needed)
___Notify Prior Caseworker of New Application (If Applicable)
___Refer for Photo ID (If Applicable)
___Discuss Payee Responsibilities
___Discuss Child Support Requirements and Sanctions (If Applicable)
___Discuss Work Requirements and Sanctions (If Applicable)
___Discuss Requirement That Changes Be Reported
Page 2 of 2 
1 2 
