Form H1036, Refugee Cash Assistance Verification Form

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Effective Date: 3/2011


Updated: 4/2018


To provide verification of the assistance the refugee client is receiving from the Refugee Voluntary Agency (VolAg).


When to Prepare

The Refugee VolAg completes Form H1036 when a client is applying for benefits and receives Refugee Cash Assistance (RCA), Resettlement Funds, Match Grant (MG) or vendor payments (VP). The information is faxed or mailed to Centralized Benefits Services (CBS) to process the client's application/renewal for SNAP, TANF or Medicaid.

Number of Copies

Prepare one copy.


The Refugee VolAg is responsible for completing Form H1036 and either faxes or mails a copy to the advisor.

File a copy in the case record.

Form Retention

Refer to the Manager's Guide for Eligibility Programs.

Detailed Instructions

Section I — The VolAg completes the applicant case information.

Section II — The VolAg provides the names of the family members receiving cash assistance. For resettlement funds, the VolAg lists the total monthly amount and the first and last month the client received the funds. For MG or RCA, the VolAg circles the type of assistance the client is receiving, the amount the client will receive over eight months and information regarding Reception and Placement (R&P) assistance.

Section III — The VolAg marks all types of assistance the client receives and all VP amounts.

Section IV — The VolAg lists the names of household members enrolled in employment services or attending English as a Second Language (ESL) classes and any additional comments.

Section V — The VolAg provides all contact information.