PURPOSE: To provide notification to the EU of a missed appointment for an office, telephone, or home interview. The notification instructs the applicant of his/her responsibility to reschedule the missed interview.
NUMBER OF COPIES AND DISPOSITION: Make two copies. Mail the original to the EU. File a copy in the case record. Maintain the form in the case record if the EU fails to reschedule a second appointment. The form may be destroyed if the EU schedules and attends the rescheduled appointment.
INSTRUCTIONS FOR COMPLETION: The form can be typed, handwritten, or the electronic version may be used.
MANUAL REFERENCE: 1120.045.35
FROM:
CASEWORKER: Enter the name of the caseworker.
TELEPHONE NUMBER: Enter the telephone number of the county office.
DATE: Enter the date this form is completed and mailed.
COUNTY OFFICE ADDRESS, CITY, STATE, AND ZIP: Enter the county office name and address or use a county label.
TO:
NAME: Enter the head of EU or individual’s name.
ADDRESS, CITY, STATE, ZIP: Enter the head of EU or individual’s complete mailing address.
RE:
CASE NAME: Enter the case name.
SUPERCASE NUMBER: When applicable, enter the 10-digit supercase number.
CASE NUMBER: Enter the case Departmental Client Number (DCN) for the head of the EU.
BODY OF THE LETTER:
The first box applies to initial, non-timely/second month applications.
MONTH/DAY/YEAR: In the space provided, enter the month, day, and year by which the applicant must contact the office to reschedule a missed interview. For initial applications, non-timely and second month applications, this date is the 30th day after the date of application.
The second box applies to timely recertifications.
MONTH/DAY/YEAR: In the space provided, enter the month, day, and year by which the applicant must contact the office to reschedule a missed interview. The date entered is the last day of the certification period.
CASEWORKER/CASE MANAGER’S SIGNATURE AND LOAD NUMBER: The caseworker/case manager should sign the form and enter his/her load number.
TELEPHONE NUMBER: The caseworker/case manager enters his/her phone number.
BACK OF THE FORM: The reverse side of the form is for the caseworker/case manager to indicate the information the head of EU/individual should have available for the interview. Place a check mark preceding the information needed by the caseworker/case manager to complete the investigation.
NOTE: Do not ask for information that is not required to be verified such as the rent amount that is not questionable or request previously verified information, such as social security numbers.