Client Exit Form Continued Income: Amount Recipient(s) Amount $ $  Social Alimony or other spousal support Security Income (SSI) $ $ Cash Social assistance/TANF Sec Disability Income (SSDI) $ $ Child Unemployment support $ Earned $ VA Service Connected $ $ Pension Veteran's from a former $ Retirement Worker’s from Social Security $ Compensation $ Private Disability Insurance $ General Other Other Sources? Sources? $ $ Source___________________ Source_________________ TOTAL MONTHLY INCOME TOTAL MONTHLY INCOME $ $ (record separately for each adult) (record separately for each adult) Non-Cash Benefits: Recipient(s) Source Recipient(s) Source   Food Stamps - Amount $ TANF child care services  WIC TANF transportation services Section 8, Public Housing, or other ongoing   Other TANF-funded services rental assistance Health Insurance Recipient(s)  Employer-provided Medicaid Health Insurance Health insurance obtained through Medicare COBRA State Children’s Health Insurance Private Pay Health Insurance Program (SCHIP) Veteran’s Administration (VA) Medical State Health Insurance for Indian Health Services
Client Exit Form Continued Income: Amount Recipient(s) Amount  Alimony or other spousal support $ Social Security Income (SSI) $ Cash assistance/TANF $ Social Sec Disability Income (SSDI) $ Child support $ Unemployment $ Earned $ VA Service Connected $ Pension from a former $ Veteran's $ Retirement from Social Security $ Worker’s Compensation $ Private Disability Insurance $ General $ Other Sources? Source___________________ $ Other Sources? Source_________________ $ TOTAL MONTHLY INCOME (record separately for each adult) $ TOTAL MONTHLY INCOME (record separately for each adult) $ Non-Cash Benefits: Source Recipient(s) Source Recipient(s)  Food Stamps - Amount $  TANF child care services WIC  TANF transportation services  Section 8, Public Housing, or other ongoing rental assistance  Other TANF-funded services Health Insurance Recipient(s)  Medicaid Employer-provided Health Insurance Medicare Health insurance obtained through COBRA State Children’s Health Insurance Program (SCHIP) Private Pay Health Insurance Veteran’s Administration (VA) Medical State Health Insurance for Indian Health Services
TAB-6-SERVICES-PLANS-CASE-NOTES-Revised-March-2017.docx