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Effective Date: 



Updated: 11/2015


To serve as verification that a Temporary Assistance for Needy Families (TANF) or medical programs client has contacted a family violence specialist for a good cause recommendation or family violence exemption.


When to Prepare

The family violence specialist completes the form indicating that an initial assessment has been made and making a recommendation for good cause or the family violence exemption.

The specialist completes and sends the form to the advisor within five days of the assessment.

Number of Copies

Complete an original only.

Filing Instructions

File the original under the Child Support tab or the Family Violence logical unit of work (LUW).

Form Retention

Refer to the Manager's Guide for form retention information.