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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)

LDSS-4770 (Rev. 2/16) TANF Services Eligible Statuses and Proof 2 B. If you do not currently receive one of the programs listed above, please tell us about any income of your family members.

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