TANF SERVICES CERTIFICATION
LDSS-4770 (Rev. 2/16) TANF SERVICES Eligible Statuses and Proof 1 TANF YOUTH SERVICES APPLICATION The information requested on this form is necessary to determine whether or not federal Temporary Assistance for Needy Families (TANF) funds may be used to provide SERVICES to you. This application form may be used by an applicant for SERVICES who is under 21 years of age. ________________________________________ ________________________________________ ___________________ SECTION ONE A. Information About the Youth Applicant 1. Applicant s Name: ________________________________________ ___________ Home Address: ________________________________________ ____________ (Street) (Apartment Number) ________________________________________ ________________________ (City) (State) (Zip Code) Social Security Number: ___________________________________ Date of Birth:______________________ (Month, Day, Year) Telephone Number: ______________________________________ ________________________________________ ________________________________________ __________________ SECTION TWO Citizen / Non-Citizen Status A.
LDSS-4770 (Rev. 2/16) TANF Services Eligible Statuses and Proof 4 Certification Decision The applicant is certified for TANF Services. All Items on page 3, must be answered Yes. The applicant is not certified to receive TANF services for the following reason(s): The …
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