The purpose of this form is to provide a systematic method for requesting and receiving income verification from local DCBS offices. Each local CAA will establish a time that is mutually agreed between the county DCBS and CAA office for submission and return of this form. The CAA staff will complete items 1 through 7, and items 9 and 11 based on information obtained from the consumer. Please remember that the "DCBS Consumer Name" refers to the name the DCBS case is listed by, which may or may not be the Head of the Household by LIHEAP definition.

1. Date Submitted - Enter the date the form is submitted to the DCBS local office.
2. Date Returned - Enter the date the form is returned to the CAA office.
3. PR- PR means PRIORITY. If there is a check mark in this column, the local DCBS office will verify the information as soon as possible and call the information back to the CAA office. Use this column only if the household is without heat or in some other emergency situation.
4. DCBS Consumer Name - Enter the name of the household member whose DCBS income or records need to be verified by DCBS.
5. SS# - Enter the Social Security Number of the person listed in item 4.
6. Grant Type - Enter the type of DCBS grant the consumer reported.
7. Amount - Enter the amount of the grant as reported by the consumer for the LIHEAP application.
8. Verified - The DCBS staff will check and initial if information contained in items 6 and 7 is verified by their records.
9. Earned Income - If consumer reports earned income, enter the amount if verification is needed
10. Ver’d - The DCBS staff will check and initial this block if information in item 9 is verified.
11. Unearned Income - Enter the amount of unearned income that the consumer has reported, if this information needs to be verified.
12. Ver’d - The DCBS staff will check and initial this block if information in item 11 is verified.
13. Notes - To be used as needed.

Date: ________________________ Component: Subsidy _____

Crisis _____

Dear: ________________________; Other _____

Based on the information provided on your application of home heating assistance, you have been denied, in accordance with 904 KAR 2116, for the reason circled below. If you would like to appeal this decision, please contact:

The Kentucky Association for Community Action state office can be contacted at 1-800-456-3452, or the Cabinet for Families and Children can be reached at 1-800-372-2973.

1 Your application was denied because the household income is too high.

2 Your application was denied because the cash and resources that you have on hand are over the limit of $1,500.00. (except when there is a household member with a catastrophic illness utilizing resources for living and medical expenses, liquid resources limit is $ 4,000)

3 Your application for assistance has been denied because you have already received the maximum allowable assistance provided in this program.

4 Your application was denied because your household did not meet the eligibility of a crisis.

5 Your application for assistance has been denied because you did not provide the information needed to determine eligibility.

6 Your application was denied because you voluntarily withdrew the application.

7 Your application for assistance was denied because the program did not have enough funds to provide the assistance.

8. Other ______________________________________

Any household denied benefits under this program must receive written notification of the denial. This notification must include the reason for denial and inform the applicant of his/her right to appeal.

1. Agency - Enter Agency name.
1. Component - Check whether the denial is for the Subsidy or Crisis Component
2. Date - Enter the date the denial was issued.
3. Dear - Enter the name of the head of household.
4. Name - Name of Agency representative who is responsible for all processing of consumer appeals.
5. Address - Address of office in which agency representative is located.
6. Phone - Telephone number where agency representative can be reached.
7. Reason for Denial - Circle the reason for the application being denied.

1. Agency - Enter Agency Name
2. Date of Report - Enter the date the report was prepared.
3. Date of Action - Enter the day on which fraud or abuse was initially suspected.
4. Brief Description of Problem - Circle type of fraud or abuse reported or suspected.
5. Agency Response - What actions did the agency take to investigate or verify the suspected case of fraud or abuse.
6. Final Resolution - What was the outcome of the investigation and what corrective actions did the agency take in resolving the case.

Agency: ________________________________________________________________

County: ___________________________________

Date of Report: ______________________ Date of Action: ____________________

SS# of Head of Household: _________________________________

Description of Complaint: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Agency Response: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Resolution: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

______________________________________________________

Report Prepared By Date

Revised 9/30/99

____________________________________________________

 Revised 9/30/99

The case review is used by the Executive Director or designee, to perform the required 2% case review for quality control. A case review form shall be completed for each case reviewed.

1. Date of Review - Date on which review is performed.
2. Head of Household Name - Enter the name of the head of the household as it appears on Application
3. Date Application Started - Corresponds to item 1 of the Application.
4. Date Application Completed - Corresponds to item 22 of the Application.
5. Date Service Provided – If different from # 4.
6. Processed Timely - Enter YES or NO dependent on if application was processed within 5 days from start and if crisis, was service provided within time limit.
7. Income Verified By - List the sources used for verification of income. Note any missing documentation.
8. Benefit Level Correct - Enter YES or NO dependent on the following: For the Subsidy component, use the percent of poverty chart and the subsidy benefit chart to determine if the benefit level provided was correct. For the Crisis component, determine if the minimum necessary to alleviate the crisis was provided and that the Allowable Crisis Maximum has not been exceeded.
9. Application Incomplete with the Following Information Missing - Enter YES or NO dependent on if all required information was entered on the application and if all required verification of eligibility criteria is present in the case file. Note any missing information.
10. Notes in Case File to Explain Unusual Circumstances - Enter YES or NO, If YES, provide an explanation.
11. Social Security Number on Application Entered Correctly and Matches All Source Documents - Enter YES or NO.
12. Target Group(s) Identified Correctly – Enter YES or No

The Case Review Summary is used to summarize the 2% case reviews performed on a weekly basis and submitted to KACA.

1. Agency - Name of CAA.
2. Report # - Number reports in sequential order with the first report being #1.
3. For Week Ending - Enter the date of the Friday for the week the case reviews represent.
4. Number of Applications Processed this Week - Enter the number of applications, approved and denied, during the same week as entered above.
5. Number of Cases Reviewed - Enter the number of cases reviewed for the week above.
6. Applications Were Received for the Following Counties - Enter the counties from which applications or cases were reviewed.

7. Note Corrective Actions Taken as Needed - Describe any corrective actions that were taken based on the case reviews.