OMB 0960-0629
Benefits Planning, Assistance, and Outreach
Benefit State Partnership Initiative
Demonstration Site pecialist Information Form
Demonstration Site (agency name or city)ID: __ ________________________________ __ __ __ __
State: _______________
Primary contact for dataIdentifying information:
Last Name: ________________________ First Name: _________________ MI: ___
Title: ____________________________________
_______
Geographic catchment area (check all that are applicable to the demonstration site):
Urban
Suburban
Rural
Geographic area in which the demonstration project is located (check only one):
Urban
Suburban
Rural
3. Date Benefit Specialist began providing services (MM/DD/YY): __ __/__ __/__ __
4. Contact Information:
Email: _______________________________________
For assistance with this form, contact Michael West by phone at (804)828-1851, by fax at (804)828-2193, or by e-mail at mwest@vcu.org.
Telephone: (__ __ __) __ __ __ - __ __ __ __
Fax: (__ __ __) __ __ __ - __ __ __ __
Street Address (it is presumed that the city and state are the same as the Site):
________________________________________________________________________
Zip Code: __ __ __ __ __ - __ __ __ __
Benefit Specialist ID: This identifier is assigned when the benefit specialist information is entered, and is required to review or enter beneficiary/recipient information.
Write it down here when the computer gives it to you: ___ ___ ___ ___ ___ ___
File Type | application/msword |
File Title | State Partnership Initiative |
Author | Mike West |
Last Modified By | Craig Hartson |
File Modified | 2003-09-11 |
File Created | 2003-09-11 |