BPAO Specialist Form (Current Version)

OMB 0960-0629

Benefits Planning, Assistance, and Outreach

Benefit State Partnership Initiative

Demonstration Site pecialist Information Form

1. Demonstration Site (agency name or city)ID: __ ________________________________ __ __ __ __

3. State: _______________

4. 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: ___ ___ ___ ___ ___ ___