Attachment ____
Eligibility Form for TANF Funded Services

Recipient Name:  ________________________________	Telephone: _____________________________
Address: _______________________________________	City: ______________________ Zip: _______________

TANF FUNDS MUST BE EXPENDED TO MEET ONE OF THE FOUR PURPOSES OF TANF
1.	Provide assistance to needy families so that children may be cared for in their own homes or the homes of relatives.
2.	End the dependence of needy parents on government benefits by promoting job preparation, work and marriage. 
3.	Prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing these pregnancies.
4.	Encourage the formation and maintenance of two-parent families.

SSN: __________________________________________	Date of Birth: __________________________________
Step 1: Citizenship/Qualified Non-citizenship Status
If the TANF program or service eligibility is based on income (i.e. needy families under TANF purpose #one or #two; the program has income requirements), the family member served MUST be a 
	____ A United States Citizen, or
	____ A qualified non-citizen

Citizenship and Qualified Non-Citizenship
Citizenship or qualified non-citizenship status is only required for “means tested benefits.”  This means eligibility for the benefit, program or supportive service is based on income.  If the family member does not meet a status criteria under Section A, B or C, (s)he is not eligible for TANF “means tested benefits”.

Section A: United States Citizen is an individual who was born in the United States, born abroad to a United States Citizen meeting specific criteria, or the individual is naturalized. Is the individual/family member a United States Citizen?  Yes   No

Section B: The family member is eligible if the relevant member of the family has one of the following INS statuses:
•	An alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act (INA);
•	An alien who is granted asylum under Section 208 of the INA;
•	A refugee who is admitted to the U.S. under Section 207 of the INA or a victim of human trafficking (these individuals must have their status verified by the Department of Health and Human Services);
•	An alien who is paroled into the US under Section 212(d)(5) of the INA for a period of at leat one year;
•	An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose removal has been withheld under Section 241 (b)(3);
•	An alien who is granted conditional entry pursuant to Section 203(a)(7) of the INA as in effect prior to April 1, 1980; or
•	An alien who is a Cuban/Haitian Entrant as defined by Section 501(e) of the Refugee Education Assistance Act of 1980.
Or, they are lawful permanent residents with a prior INS status identified above
Or, they are without a prior INS status listed above, and they were in the U.S. prior to August 26, 1996.

Does the individual/family member meet one of the above criteria in Section B?  Yes   No

Section C:  The family member is eligible if the relevant member of the family meets one of the following two circumstances below. Does the family member meet one of the two circumstances below?  Yes   No
•	The relevant members are lawful permanent residents who are without prior INS status (above) and who entered on or after August 22, 1996;
•	Or the relevant members are aliens who have been battered or subjected to extreme cruelty, or whose children/parents have been battered or subject to extreme cruelty.
If yes, the family is not eligible until five years after the date of entry.  Please provide the date of entry ___/___/_____.

If either line in Step1 is selected, go to Step 2. If neither line is checked, the person or family is NOT eligible for TANF funded services or programs if eligibility is based on income. The following toolbox has been provided to assist in the determination of citizenship/qualified non-citizenship status.

Step 2: Family Definitions
The family requesting services includes:
	____ A parent or relative caring for one or more children (see definition of “child” below)
	____ A pregnant woman, or

Child: a dependent person under 18 (or under 19 who is still a full-time student in high school or at the equivalent level of vocation or technical training), who has never been married or whose marriage was annulled and whose eligibility is being determined.

Parent:  includes a mother, father, adoptive mother and adoptive father.

Non-Custodial Parent:  the parent is not in the household of the child (see definition for child above) whose eligibility is being considered. Both the non-custodial parent and the child must live in the State of Florida.

Blood Relative:  including those of half-blood, within the relationship of siblings, first cousins, nephews, nieces, aunts, uncles and individual of preceding generations as denoted by prefixes of grand, great, great-great, etc. This group includes relatives within the fifth degree of kinship to the dependent child; therefore, this includes first cousins once removed, but not the second cousins.

	____ A non-custodial parent (see definition of “non-custodial parent” below)

If any line in Step 2 is checked, continue to Step 3. If none is checked, the individual is only eligible for services accomplishing/supporting TANF purposes #3 or #4.

Step 3: Determination of Need
Depending on the purpose served, program, benefit or service, the family’s income level may have to be determined. For TANF purpose #1 (the Temporary Cash Assistance program), DCF determines if the family meets the “needy” requirements. For programs, services or benefits served under TANF purpose #2, the RWB or RWB provider may have to determine if the family is “needy”.  Although TANF purposes number #3 and #4 do not require a determination of “needy”, the RWB or State may restrict benefits and services to individuals and families below a certain income.

A.	What TANF purpose does the program, benefit or service accomplish? 
____________________________________

B.	Does eligibility have income requirements?  Note, if TANF purpose number #2 were written above, the answer is “yes”. If the program is a State special project, and income requirements are a factor of eligibility, the answer is “yes”. If the benefit or service is provided by the Regional Workforce Board through local operating procedures, and the eligibility requirements include income level, the answer is “yes”.   Yes   No

C.	If yes, does the family meet income eligibility requirements?  Yes   No
	If income is strictly based on Florida’s definition of “needy”: 
•	Does the family receive Temporary Cash Assistance, relative caregiver program payments, food stamps or are the children in the family eligible for Medicaid?   Yes   No 
•	Is the family’s total income less than 200% of the Federal Poverty Level?   Yes   No
If income is based on reporting instructions, local operating procedures or guidance, please review the appropriate materials for income eligibility determination. 

D.	If the program, benefit or service requires a determination of “needy” or eligibility is based on income, the applicable family member(s) MUST be a citizen or qualified non-citizen?  According to Step 2, does the applicable family member meet citizen or non-qualified citizen criteria?  Yes   No.  If NO, the family is not eligible for the program, benefit or service.

According to Federal Regulations, benefits and services provided by TANF are restricted.  Each applicable family member is required to supply his or her Social Security Number or apply for an SSN.  The RWB should help the family apply for a SSN if help is needed.  Did the applicable family members provide his or her SSN?  Yes   No . 

Name: _______________________SSN ____________________ or Application Filed?  Yes   No 

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Name: _______________________SSN ____________________ or Application Filed?  Yes   No

Step 4: Social Security Numbers																									       

Step 5: Self Attestation	

I ______________________________________ certify, to the best of my knowledge, the above information is true.  

Name: ______________________________________________ SSN: ____________________________ 

Date:___________________

Signature: ___________________________________ Phone Number:____________________________

Address: 

_____________________________________________________________________________________
Street Address					City			     State		                  Zip Code

__________________________________	_______________________________________
RWB partner printed name					RWB partner signature

_____________________________________	___________________________________
Date							Phone Number

Comments: ________________________________________________________________________________________