Release 88:  Effective January 1, 2018

Temporary Assistance For Domestic Violence Survivors Program (TA-DVS) -
F.   Notices and Required Forms


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  1. Decision Notices
  2. Using a basic decision notice (see OAR 461-001-0000) is appropriate in TA-DVS cases. Notices should be sent to a safe mailing address or hand-delivered.

    To approve program eligibility for TA-DVS, use the Notice of Decision and Action Taken (DHS 456DV). This notice includes the dates of eligibility as well as information how the program operates. The notice also explain clients’ hearing rights.

      If the program remains open for the entire 90 days, there is no reason to send another decision notice at the end of the 90-day eligibility to close or end TA-DVS, as the DHS 456DV includes the program eligibility dates and, as such, meets the requirements of both an approval and closure notice.

    To end or close the TA-DVS Program prior to the end of the 90-day periods, use the Notice of Decision and Action Taken (DHS 456). Document the reason the program is ending early (i.e., no eligible child; moved out of state; reconciled with the abuser; etc.).

    To deny the application or a payment for TA-DVS, use the DHS 456 form. Document the reason for the denial.

    Use TANF denial or closure codes when appropriate. For specific TA-DVS-related denials or closures, use the following codes:

      VE no emergent need (i.e., no safety concern related to domestic violence)
      VM closed due to reconciliation with abuser
      VS does not meet definition of domestic violence in OAR 461-001-0000
      VW Waiver Removed (when eligibility is based on waiving a TANF requirement such as citizenship)
      VN 90-day eligibility has expired (only needed if the client did not receive the DHS 456DV with the eligibility dates included)


      Exercise caution when issuing notices to DV households.

      • When possible, hand-deliver in the office or at the domestic violence shelter;

      • Verify with the client that using the mailing address is safe.

      If unable to mail, narrate the notice and keep a copy in file.

      Notice Situations; General Information Rule
      461-175-0200 — Notice Situations; General Information

  3. Decision Notice Approving TA-DVS (DHS 456DV)
  4. The DHS 456DV is the notice that informs the survivor they have been approved for the TA-DVS program. The notice also informs the survivor the 90-day eligibility period begin and end dates.

    If the DHS 456DV has been given to the survivor, workers do not have to send another decision notice for the 90th day.

  5. Safety Assessment (DHS 7802)
  6. Screening for domestic violence happens in several ways in Oregon. On the DHS 415F, generic questions on safety are asked. The Safety Assessment (DHS 7802) asks in more detail questions on safety. Use the DHS 7802 to help determine if they may need to apply for TA-DVS, need a referral to the DV Advocate and determine their level of safety.

  7. Self-Sufficiency Domestic Violence Assistance Agreement (DHS 1543)
  8. In April 2004, the Self-Sufficiency Domestic Violence Assistance Agreement (DHS 1543) became a mandatory form for use in case planning with survivors of domestic violence who are currently experiencing domestic violence or who have been approved for Temporary Assistance for Domestic Violence Survivors (TA‑DVS).

    The DHS 1543 asks for the immediate plan to address safety concerns and the plan to stay safe from abuse. These sections help to guide the conversation in developing the required Safety Plan and increase stabilization.

    The immediate plan should address the actions a survivor feels they need to complete when leaving the office to stay safe.

    The plan to stay safe should include a more long term concept of what is needed. Remember that long term could mean two weeks, two months, etc.

  9. Client Safety Packet (DHS 8660)
  10. The Client Safety Packet is used when anyone reports to their worker that they have a a safety concern pursuing the noncustodial parent. The form contains:

    Claim of Risk – This document is used if the survivor is fine to pursue child support, they just do not want certain information shared with the noncustodial parent.

    Good Cause – This document is used if the survivor cannot have DCS to pursue support due to a safety concern or the child was born following incest or rape or the child is being placed into adoption.

  11. Authorization of Cash Payment (MSC 437)
  12. The Authorization of Cash Payment form (MSC 437) is used to request and authorize cash payment issuances in the Special Cash Pay (SPL), Revolving Fund and the EBT immediate issuance (EBISS) system.

    Do not send the MSC 437 to business entities.

    The MSC 437 needs to be signed by the worker requesting payment, and signed and authorized by a DHS worker with signature authorization.

  13. Self-Sufficiency Domestic Violence Motel Use Agreement (DHS 1543M)
  14. The DHS 1543M was created in 2013 for guidance around access to motels. Before motels are accessed, workers should be asking the survivor if they have tried to locate other housing options, such as:

    If there is no place for the survivor to go and there is a safety need, we can look at motel payments. Things to keep in mind:

      Signature is not required on the Self-Sufficiency Domestic Violence Motel Use Agreement (DHS 1543M), but is preferred. If you are unable to get a signature, you will need to have the conversation with the survivor and narrate that the discussion occurred.

  15. Notice of Decision and Action Taken (DHS 456)
  16. The Notice of Decision and Action Taken is used in TA-DVS cases to deny TA-DVS or TA‑DVS payments.

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