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)
Source of income A. NET Wages C. SSI D. Child Support E. Other
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
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
Source of Income Net Wages SSI Child Support TANF Grant Other
Expected month 1 $ $ $ $ $
Expected month 2 $ $ $ $ $
Expected month 3 $ $ $ $ $
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)