Eligibility and Benefit Calculation Worksheet

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                                                            Temporary Assistance for Domestic Violence Survivors (TA-DVS)
                                                                   Eligibility and Benefit Calculation Worksheet
       Children, Adults and Families

Step 1: Determine eligibility for the program:
      Find the TANF countable income standard for the number of persons in the TA-DVS household:                                                        $
      Fill in the chart below: (TANF grants are not counted in TA-DVS eligibility calculations)
                                                                    B. Unemployment
                         Source of income        A. NET Wages                                                           C. SSI           D. Child Support                 E. Other
                                                                          Benefits
             Amount received in budget month            $                           $                                   $                        $                         $

1           Total of all columns (A through E):         $

2                Amount controlled by abuser *        -$                 * Such as income in a joint checking or savings accounts or child support paid by
                                                                         abuser (Even if the money is earned by the client if accessing the income would put the
3       Amount used to address safety issues          -$                 client at risk of DV)

4       Amount client no longer can access **         -$                 ** Such as money used prior to emergency, taken by abuser or stolen by another
                                                                         person
    Subtract rows 2-4 from row 1 to get money
                                                      =$
       available for current emergency needs
                                                                          Rent/                                     Transportation       Child
                                                                                            Utilities       Phone                                    Medical       Food            Other
    Subtract living expenses for budget month          -$                Mortgage                                       Costs            Care
                                                                     $                  $               $           $                $           $             $               $

                                                                         If the total available is less than the TANF countable income standard (listed above),
                                Available income      =$
                                                                         the client meets the income requirements for TA-DVS.




                                                                 Page 1 of 2                                                                                       DHS 1542 (12/08)
Step 2: Determine income available over the 90 day eligibility period

                                                                                                                                                                 A. Monthly
Source of Income               Net Wages                     SSI               Child Support                 TANF Grant                     Other
                                                                                                                                                                    Total


    Expected month 1      $                          $                    $                              $                          $


    Expected month 2      $                          $                    $                              $                          $


    Expected month 3      $                          $                     $                             $                          $

                               Rent/                                   Transportation
                                             Utilities       Phone                          Child Care            Medical            Food               Other              Total
B. Monthly Expenses           Mortgage                                     costs
                          $              $               $            $                 $                     $                 $                  $                  $

                     Month 1: $                                            Adjustments:
  C. Client’s income                                                                                          Subtract any income unavailable to the client because it is controlled
  minus (A minus B) Month 2: $                                                                                by the abuser or any income the client used or needs to remain free
     living expenses                                                                                          from the violence.
                     Month 3: $

• This calculation (C.) can be used to help establish what financial resources the client has available to help meet their current or future
  needs, including housing needs.
• TA-DVS funds are not intended to meet on-going or basic needs and should be used to address specific emergent or stabilization needs
  over the 90 day eligibility period and should not exceed a total of $1200.00 over the eligibility period.
• Timeliness is critical in supporting the survivor to stay free from domestic violence and a TV-DVS payment should not be delayed pending
  receipt of income when safety is at risk.
• TA-DVS payments are made either using the dual payee process or vendor pay process unless doing so would put the client at greater
  risk of domestic violence. If the vendor/dual payee process can’t be used narrate the reason why in TRACS.

                                                                     Page 2 of 2                                                                                DHS 1542 (12/08)