Instructions: Yes – if this individual was referred for Tribal TANF
No – if this individual was NOT referred for Tribal TANF
See TANF: Special Considerations in Budgeting: Concurrent receipt of State and Tribal TANF 340:10-3-57(c).

Instructions: Check this box if the person aged, blind, or disabled and has been referred to SSA to apply for SSI or social security.

Instructions: Use this field to indicate if this person is included in the current household.
See SNAP: Food benefit household composition 340:50-5-1.
See SNAP: Person who cannot be separate food benefit households 340:50-5-3.
See TANF: Household composition 340:10-3-56.
See Child Care: Household composition and income consideration 340:40-7-6.
This field defaults to yes and will need to be unchecked if the person if not in the current household. This is the control that lets the system know if it needs to include this person on the FSS-1 when you print it.

Instructions: Enter the first name at it appears on the Oklahoma birth certificate to attempt to verify citizenship.

Instructions: Enter the middle initial as it appears on the Oklahoma birth certificate to attempt to verify citizenship.

Instructions: Enter the last name as it appears on the Oklahoma birth certificate to attempt to verify citizenship.

Instructions: Enter the city of birth to verify citizenship for this person.
This field should be updated only if the Citizens/Alien Status of this person in “Citizen”. This field should be updated only if the Citizenship Verification Status of this person is “waived”. This information will be saved only if this person requires verification of citizenship.
For this field to be saved all of the following criteria must be met:

1. The Citizenship Verification Status of this person be “waived”. (If citizenship has already been verified by any other method, the information in this field will not be saved).
2. The person has a Benefit Type of Medical Assistance – Title XIX, SLMB – Specified Low Income Medicare Beneficiary, Qualified Disabled Working Individual, or Optional TB Coverage Group.
3. The person has a Benefit Status of “added to benefits”.
4. The Medical Action Taken is “application, “unfinished”, or “vending”.

The Re-send to Oklahoma Department of Health box is checked “Yes”. (The information will be saved automatically the first time it is updated, for any subsequent updates the “Re-send to Okla. Dept. of Health box must be checked “Yes”).

Instructions: Enter the county of birth to verify citizenship for this person.
This field should be updated only if the Citizenship Verification Status of this person is “waived”. This information will be saved only if this person requires verification of citizenship.
For this field to be saved all of the following criteria must be met:

1. The Citizenship Verification Status of this person be “waived”. (If citizenship has already been verified by any other method, the information in this field will not be saved).
2. The person has a Benefit Type of Medical Assistance – Title XIX, SLMB – Specified Low Income Medicare Beneficiary, Qualified Disabled Working Individual, or Optional TB Coverage Group.
3. The person has a Benefit Status of “added to benefits”.
4. The Medical Action Taken is “application, “unfinished”, or “vending”.

The Re-send to Oklahoma Department of Health box is checked “Yes”. (The information will be saved automatically the first time it is updated, for any subsequent updates the “Re-send to Okla. Dept. of Health box must be checked “Yes”).

Instructions: Enter the state of birth to verify citizenship for this person.
This field should be updated only if the Citizenship Verification Status of this person is “waived”. This information will be saved only if this person requires verification of citizenship.
For this field to be saved all of the following criteria must be met:

1. The Citizenship Verification Status of this person be “waived”. (If citizenship has already been verified by any other method, the information in this field will not be saved).
2. The person has a Benefit Type of Medical Assistance – Title XIX, SLMB – Specified Low Income Medicare Beneficiary, Qualified Disabled Working Individual, or Optional TB Coverage Group.
3. The person has a Benefit Status of “added to benefits”.
4. The Medical Action Taken is “application, “unfinished”, or “vending”.

The Re-send to Oklahoma Department of Health box is checked “Yes”. (The information will be saved automatically the first time it is updated, for any subsequent updates the “Re-send to Okla. Dept. of Health box must be checked “Yes”).

Instructions: Enter the mother’s maiden name to verify citizenship for this person.
This field should be updated only if the Citizenship Verification Status of this person is “waived”. This information will be saved only if this person requires verification of citizenship.
For this field to be saved all of the following criteria must be met:

1. The Citizenship Verification Status of this person be “waived”. (If citizenship has already been verified by any other method, the information in this field will not be saved).
2. The person has a Benefit Type of Medical Assistance – Title XIX, SLMB – Specified Low Income Medicare Beneficiary, Qualified Disabled Working Individual, or Optional TB Coverage Group.
3. The person has a Benefit Status of “added to benefits”.
4. The Medical Action Taken is “application, “unfinished”, or “vending”.

The Re-send to Oklahoma Department of Health box is checked “Yes”. (The information will be saved automatically the first time it is updated, for any subsequent updates the “Re-send to Okla. Dept. of Health box must be checked “Yes”).

Instructions: Enter the information needed to verify citizenship for this person and check this box to resend the information to the Oklahoma Department of Health to try to verify citizenship. This field should be updated only if the Citizenship Verification Status of this person is “waived.” This information will be saved only if this person requires verification of citizenship.
For this field to be saved all of the following criteria must be met:

1. The Citizenship Verification Status of this person be “waived”. (If citizenship has already been verified by any other method, the information in this field will not be saved).
2. The person has a Benefit Type of Medical Assistance – Title XIX, SLMB – Specified Low Income Medicare Beneficiary, Qualified Disabled Working Individual, or Optional TB Coverage Group.
3. The person has a Benefit Status of “added to benefits”.
4. The Medical Action Taken is “application, “unfinished”, or “vending”.

The Re-send to Oklahoma Department of Health box is checked “Yes”. (The information will be saved automatically the first time it is updated, for any subsequent updates the “Re-send to Okla. Dept. of Health box must be checked “Yes”).

Instructions: List the name of the school being attended for each household member.

Instructions: Indicate if this person attends school part or full time.
See Students 340:50-5-45.

Instructions: This field is used to document how School Attendance was verified for school age children.
See School Attendance 340:10-13-1.