Download Temporary Assistance for Domestic Violence Survivors (TA-DVS)

Temporary Assistance for Domestic Violence Survivors (TA-DVS)
Eligibility and Benefit Calculation Worksheet
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 initial month eligibility calculations)
Source of income 
A. NET wages
Amount available in budget month
$
1
Total of all columns (A through F):
$
2
Amount controlled by abuser *
-$
3
Amount used to address
safety issues**
-$
4
Amount client no longer can access ***
-$
Subtract rows 2-4 from row 1 to get money
=$
available for current emergency needs
B. Unemployment
benefits
C. SSI
$
0.00
D. Child
support
$
$
$
E. Cash on
hand
F. Other
$
$
* 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 client at
risk of DV)
** Such as money used for temporary housing, safety measures, etc.
*** Such as money used prior to emergency, taken by abuser or stolen by another
0.00 person, money used to pay household or other expenses
Subtract living expenses not yet paid for
budget month
-$
0.00
Available income
=$
0.00
Rent/
mortgage
$
Utilities
$
Phone
$
Transportation
costs
$
Child
care
$
Medical
$
Food
$
Other
$
If the total available is less than the TANF countable income standard (listed above), the
client meets the income requirements for TA-DVS.
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DHS 1542 (01/11)
Step 2: Determine income available over the 90 day eligibility period
Source of income 
Net wages
SSI
Child support
TANF grant
A. Monthly
total
Other
Expected month 1
$
$
$
$
$
$ 0.00
Expected month 2
$
$
$
$
$
$ 0.00
Expected month 3
$
$
$
$
$
$ 0.00
B. Monthly expenses
Rent/
mortgage
$
Month 1: $ 0.00
C. Client’s income
minus (A minus B) Month 2: $ 0.00
living expenses
Month 3: $ 0.00
Utilities
$
Phone
$
Transportation
costs
$
Child care
Medical
Food
Other
$
$
$
$
Total
$ 0.00
Adjustments:
Subtract any income unavailable to the client because it is controlled
by the abuser or any income the client used or needs to remain free
from the violence.
 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 TA-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.
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DHS 1542 (01/11)