Section A: To be completed by the participant
*I understand that I may be eligible to receive a one-time, lump-sum cash assistance severance benefit payment of $1,000 instead of ongoing Temporary Cash Assistance (TCA). I certify that I have received TCA for at least six consecutive months in Florida since 10/1/96. If I receive the Cash Assistance Severance Benefit payment, I may not apply for Temporary Cash Assistance again for six months, unless an emergency is demonstrated to the Regional Workforce Board. I further understand that if I receive a Cash Assistance Severance Benefit and reapply for TCA within six months due to an emergency, I will have to repay the amount received.
Privacy Statement
I understand that I am required by law to provide my social security number(s) or proof that I have applied for a social security number if I do not currently have one to receive TANF funded benefits/services. This is mandatory under the Social Security Act (42 U.S.C. 1137). If I do not have a social security number and have not applied for a social security number, I can request help with filing an application. The social security number is used to administer the program, including determining eligibility, attributing the receipt of services, correspondence and participation to my case, as well as for reporting purposes.
