Form 2064, Eligibility Worksheet

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.


Effective Date: 4/2004


Updated: 4/2004


  • To document verification of financial eligibility for community care services.
  • To document the financial eligibility status for community care services.
  • To document compliance with the requirement that Individuals be informed of their rights and responsibilities.


When to Prepare

The caseworker completes Form 2064 and files it in the case record for each application and each review of financial eligibility. When reviewing functional eligibility only, the caseworker will sign the certification box in the far lower right-hand corner to certify that the Individual remains functionally eligible.

Form Retention

Form 2064 is retained as part of the case record for three years and 90 days after the case is closed.

Detailed Instructions

Individual Name — Self-explanatory.

Individual No. — Self-explanatory.

Immediate or Expedited Services Responses — Check this box for applications in which the expedited eligibility policy is appropriate. Enter the date the authorization begins in the blank provided; then sign and date the approval line, certifying that the applicant is approved for immediate referral for services.

Financial Eligibility Determination — Complete this section of the form at initial applications and at the financial redetermination.

A. Categorically Eligible — Check this box if the applicant or Individual is categorically eligible. Indicate the source of eligibility (SSI, TANF, MAO, QMB/SLMB, CA, SNAP) under Reason. Under How Verified, check the box to indicate how categorical status was verified (3087, 2067, IAS/ME, DCU), and enter the verification date under Date Verified.

B. Income Eligible — Check this box if the Individual or applicant is income eligible. If this box is checked, the source(s) of income must be documented in the Income section.

C. Financially Ineligible — Check this box if the Individual or applicant is financially ineligible. If this box is checked, documentation of ineligibility must be recorded in the Income and Resources sections.

D. Referral to AAA — Check this box if the Individual or applicant is age 60 and Individual was advised of the TDoA-AAA toll-free number.


Record the amount of income, the type and date of the verification used, and the date verified. If the verification document is in the case record, check the "document filed" box only.

1. Social Security (including SMIB) — Record the amount of Social Security benefits including the SMIB payment.

2. SSI Spouse — Record the amount of supplemental security income received by a spouse if the Individual is income eligible.

3. VA (less Aid-&-Attendance) — Determine whether veterans' payments include aid-and-attendance, home-bound benefits, or payments for medication. If applicable, subtract additional benefits from the total payment. Record the verified veterans' payments.

4. Railroad Retirement Benefits — Record the benefit amount, including SMIB.

5. Other Retirement Benefits — Record the benefit amount, including any insurance premiums.

6. Dividend Income — Record the dividends received from stocks or bonds.

7. Money from Oil, Gas, Royalties — Record the net average monthly income received from oil, gas, or royalties.

8. Income-producing Property — Record the net income received from income-producing property.

9. Farm Income — Record the net income.

10. Money from Other Sources — Enter the amount of income from any other source.

Total Income — Enter the total amount of all nonexcluded income.


Enter the amount or value of each applicable resource. Check the "document filed" box if a document verifying the resource is filed in the case record. If a document verifying the resource is not in the case record, document the date verified and source of verification.

1. Checking Account — Record the amount of money in the checking account(s).

2. Savings Account, Certificate of Deposit (CD), Money Market Funds — Record account(s).

3. Cash on Hand, Safe Deposit Box — Record the amount of cash on hand or in a safety deposit box.

4. Stocks, Bonds — Record the current market value of stock or bonds.

5. Nonproductive Property — Record the current market value of nonincome-producing property, minus recorded encumbrances.

6. Nonexempt Vehicles — Record the current market value of nonexempt licensed or unlicensed vehicles, minus recorded encumbrances.

7. Other Resources — Record the equity value of all other resources.

Total Resources — Enter the total amount of all nonexcluded resources.

Less Monthly Income — Subtract the amount of the applicant's/Individual's monthly income if it is actually included in the checking or savings account or cash on hand.

Countable Resources — Enter the net amount of resources calculated by subtracting the monthly income from the total resources.

Denial Resulting from Unmet Need — The caseworker signs and dates this box if the Individual is being denied as a result of no unmet need for CCAD services.

Eligibility Certification — The caseworker completes and signs the first block for applications and financial/functional redeterminations to certify that the Individual met all eligibility criteria. The second block is used to certify that functional eligibility only was redetermined.

Check the appropriate box to document that the Individual's rights and responsibilities were discussed, and/or that Form 2307 was given to the Individual. By checking the third box, the caseworker is certifying that the Individual was presented with Form 1350, Opportunity to Register to Vote, and that a copy of the form, signed by the worker, is filed in the case folder. Check the fourth box if the Individual voluntarily indicates that s/he is not a U.S. citizen.

Top of Page