Free 48190.pdf - Indiana

APPLICANT JOB SEARCH REFERRAL WORKSHEET
State Form 48190 (4-97) / IMP 0019

Date (month, day, year)

Screener's initials

This form is CONFIDENTIAL according to 470 IAC 1-2-7; 470 IAC 1-3-1; AND 470 IAC 6-1-1.
AJS worker's initials

Name of applicant

Social Security number

Applicant's number

PART I The prescreener is to complete the following questions for each household member age 16 or older who is applying for TANF and / or Food Stamps, regardless if the individual is seen in person or not. Enter "N" for "No" and "Y" for "Yes". 1. 2. 3. 4. Does the applicant have an active IMPACT case? (Check WPA1 by Social Security number.) Is the applicant being added to an existing assistance case? Is the applicant applying for an "add-a-program"? Is the applicant assigned to the control group?

If yes is answered to any of the above questions, DO NOT refer the applicant to the designated worker for Applicant Job Search. If no is answered to all of the above questions, continue to Part II. PART II If the applicant is requesting TANF or TANF / FS complete Section A. If the applicant is requesting Food Stamps only, complete Section B. If applicable, provide comments in the last column of each question. SECTION A-TANF 1. Is the applicant under 18 years of age? 2. Is the applicant disabled (mentally or physically unable to work)? 3. Does the applicant care for a disabled household member? 4. Is the applicant a VISTA Volunteer? 5. Is the applicant a caretaker of a child under the age of twelve weeks? (In accordance with the phase in schedule for this exemption) If no was answered to all of the above questions, make an appointment for the applicant with the applicant job search worker according to established procedures. If yes was answered to any of the above, discuss with the designated personnel the appropriate action needed. SECTION B-FOOD STAMPS 1. Is the applicant 16 or 17 years of age and attending school at least half-time? 2. Is the applicant 60 years of age or older? 3. Is the applicant enrolled as a student at least half-time? 4. Is the applicant incapacitated (mentally or physically unable to work)? 5. Does the applicant care for an ill or incapacitated person? 6. Is the applicant employed at least 30 hours or its equivalent? (Equivalent means the applicant must receive wages of the Federal minimum wage multiplied by 30 hours.) 7. Is the applicant a caretaker of a child under the age of six? 8. Is the applicant receiving unemployment compensation benefits? 9. Is the applicant participating in a drug / alcohol treatment program? If no was answered to all of the above questions, make an appointment for the applicant with the applicant job search worker according to established procedures. If yes was answered to any of the above, discuss with the designated personnel the appropriate action needed.