Table VI - Verification and Interface Match

 

Effective Date:  February 1, 2018

Previous Table

 

The eligibility agency must attempt to verify all factors of eligibility electronically before asking client to provide hard copy verifications. 

This table shows the interface matches that are available and gives EXAMPLES of hard copy verifications that may verify the information

you need, although not every example listed will verify all of the information shown under the Eligibility Factors column.  Any other

reasonable method of verification can be used as long as it provides the information needed to determine eligibility.

 

Eligibility Factor

Interface or Match

Other

U.S. Citizenship;

Age; Identification

Electronic Interface

SCHIP

See Table IV

Alien (INS) Status

Electronic Interface - Social Security screens, Alien Registration

Alien Registration Card

Correspondence from the Department of Homeland Security

Social Security Number;

Social Security Claim #

Electronic Interface

Birth Record

SAVE

SCHIP

SOLQ

Social Security Card

SSA form 5028 or 2880

Birth Certificate showing SSN applied for

Official Social Security document

Utah Residence; Resident of an Institution

Electronic Interface

New Hire Registry

Prisoner System Information

Current Utah Driver’s license

Employment payroll check stubs

Current UTES registration

House payment receipt

Current rent receipt

Utah telephone book listing (referenced)

Tribal Record correspondence

Children's residence usually follows that of parents

Nursing home resident (unless placed by another state)

Form 131- Affidavit of Intent to Become a Utah Resident; or other statement of intent to remain in Utah.  Duty of Support

Relationship (Including Specified Relative); Paternity

Electronic Interface, Birth Record

Self-declaration of relationship (unless the agency has conflicting information) 

Birth Certificate

Court Order

Marriage Certificate

DWS Form 941 - Acknowledgment of Paternity

“Voluntary Declaration of Paternity” form filed with Vital Statistics

County Records

Adoption placement or finalization forms (placement forms may be used to determine that child is not with birth parents)

Death records

Divorce records

Documents from other state agencies stating verified relationship

Duty of Support

 

Completed Application for Child Support Enforcement on each non-custodial parent

Pregnancy

 

Self-declaration (unless the agency has conflicting information) 

Current physician's or nurse mid-wife’s statement

Current statement from Planned Parenthood

Statement from a health clinic

School Attendance

 

DWS form 126

Telephone contact with school

Application for Other Benefits

Electronic Interface - Paris (VA income), Workers Comp, Social Security, Unemployment

Statement from other agency

American Indian/Alaska Native Status

 

Copayment exemption requires verification of status after the client has had reasonable time to provide verification.

 

o    Tribal Identification/Enrollment Card with Number

o    Certificate of Degree of Indian or Alaska Native Blood (CDIB) signed by the Bureau of Indian Affairs (BIA)

o    Tribal court documents.

o    The tribal documents must contain identifying information about the client. IE, name, date of birth.

o    The tribe must be recognized by the Federal government. Click on the following link for a list of federally recognized tribes:

https://www.federalregister.gov/documents/2017/01/17/2017-00912/indian-entities-recognized-and-eligible-to-receive-services-from-the-united-states-bureau-of-indian

 

o    Indian Health Services (IHS) Face Sheet. An Indian Health Services IHS face sheet is a medical record certified by IHS as being from their original records.

o    The face sheet must contain identifying information about the client. IE, name, date of birth.

Earned Income

Wages;

Self-Employment

Electronic Interface, Wages Work Number

New Hire Registry

 

Employment payroll check stubs

Employer's wage record

Statement from employer

Self-employment records

Copy of most recent tax return

Training, Work Study

 

Award letter

Contracts

Earned income in-kind (food, clothing, free housing, etc.)

 

Employer's records

Statement from employer

Written agreement

Unearned Income

Social Security Benefits (SSA);  Supplemental Security Income  (SSI); VA Benefits; Retirement; Labor Union Benefits; Pensions; Annuity; Disability Compensation; Scholarships/loans; Tribal Income; Cash gifts and prizes

Electronic Interface, Social Security Screens

SOLQ (does not show correct amount if deductions are being taken out of benefits.  Compare both the BDX and the SOLQ to verify the correct amount is counted.)

Client statement of benefits until information appears on the SDX/BDX

 Award letter

 Legally acceptable copy of check

 

Bank statement showing direct deposit specifying  source of income

Tribal Records

Unemployment Compensation

Electronic Interface, Unemployment

Statement from DWS

Bank statement showing direct deposit

 

Alimony and Child Support

Electronic Interface, Recovery Services screens

County Clerk records

Divorce decree or other court order about payments including judgment for past due amounts.

Copies of checks received

Statement from ORS

Dividend and Interest

 

Bank Statements, dividend letters or statements

Currently posted saving passbook

Current credit union statement

Internet on-line banking

Real Property Sales

 

Sales Contract

Mortgage

Payment of household

expenses by others

 

Client's statement

Form 702 - Statement of Contribution

Form 17 - Statement of Head of Household

 Expenses 

Health Insurance

Electronic Interface

Receipt for health insurance premiums paid

Insurance records/billing statement

Check stubs/statements showing amount paid by individual

Medicare Part A & B Premium Amounts

Electronic Interface - Social Security screens

Medicare Card

Official document from SSA

Alimony and Child Support Paid Out

Electronic Interface, Recovery Services screens (Unemployment Claim Adjustment Field)

Court order showing alimony or child support owed and copies of checks showing payments made

Income tax records

Medical bills owed

 

Copies of medical services received and current statement of amount owed

Statement from provider of amount owed

Other

TPL: Auto No Fault, Health (hospital),  Accident, Homeowners

 

Policies

Insurance Card

Written or verbal notice from ORS

Client's statement

Health Insurance Coverage

 

Policies

Insurance Card

Written or verbal notice from ORS

Client's statement