Fillable Community Service | Volunteer Verification Form (Lehigh Carbon Community College)

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Community Service | Volunteer Verification Form (Lehigh Carbon Community College)

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A T T A C H M E N T 9
Community Service | Volunteer Verification Form
FAX this form to:
Tamara Redfern
LCCC KEYS Facilitator
610-799-1744
Required Number of Hours
(CAO or E&T Contractor Completes)
Minimum Monthly Hours:
Maximum Monthly Hours:
INSTRUCTIONS: Please mail or FAX the completed form within 10 days of receipt to the office listed above.
See reverse for detailed directions. Questions? Call the Statewide Customer Service Center 1-877-395-8930
SECTION I. Volunteer | Agency Information
Name of Volunteer
Birthdate
Last 4 SSN
Address of Volunteer
City
State
Zip Code
Name of Agency
Address of Agency
SECTION II. Community Service Activity Information
Start Date of Service
MM-DD-YYYY
Expected End Date of Service*
MM-DD-YYYY
Transportation Provided by Agency at No Cost?
YES NO
Monthly Schedule of Service
S
M
T
W
TH
F
S
Estimated
Weekly
Hours
Week 1
Week 2
Week 3
Week 4
Total Monthly Estimated Hours
3
Description of Tasks
Performed:
SECTION III. Agency Certification
COMMUNITY SERVICE AGENCY CERTIFICATION:
I hereby certify that our organization is a nonprofit with 501(C) (3) or 501(C) (4) status that meets all applicable federal, state, and local laws and the above named
volunteer is registered with our agency to complete community service for the hours and period as indicated above. I understand that this community service verification
form is used to verify up to six months of community service participation. I also understand that our agency must report any changes in participation to the
Pennsylvania Department of Human Services within 10 days from the date the change occurred.
X
Signature of Site Manager
Name of Site Manager (please print)
Date
Section IV. Reporting Changes (Complete this section if updating an existing form.) Mail or fax within 10 days from date change occurred.
Actual End Date
Other Changes (Please explain below)
Signature of Site Manager
Name of Site Manager
Date
MM-DD-YYYY
X
Monthly Schedule
Instructions
1. Mark an ‘X’ on the
expected days of service.
2. Enter the total weekly
hours in the Estimated
Weekly Hours column.
3. Total the monthly
estimated hours.
(Circle one)
* No more than 6 months from start date. If community service is expected to continue beyond 6 months, enter 6 months from start date. A new form is required every 6 months.
PERM5C-c
Community Service | Volunteer Verification Form Instructions
An individual who is participating in the required number of hours determined by the County Assistance Office (CAO) may be
considered meeting the ABAWD work requirement and therefore not subject to time-limited SNAP (food stamps) benefits.
This form is used to document community service participation for up to 6 months of participation at a time.
If there are any changes in participation, e.g., the individual stops participating or participation falls below the minimum
monthly hours of participation, the agency must report this change to the Department of Human Services within 10 days from
the date the change occurred.
Who may complete the form: The form may be completed only by an organization or agency that is providing a community service
opportunity to the applicant or recipient. Note: The
Required Number of Hours
section is completed by
the CAO or E&T contractor based on the hours computed by the CAO and listed on the Employment
Development Plan.
Who signs the form: Only the site manager (or supervisor) who can attest to the community service agreement may sign the
form.
General form completion The information on the form must be complete and legible.
requirements: A signature by the site manager (or supervisor) is required.
Reporting changes: Complete Section IV and fax to (555) 555-555 or mail to:
CAO, Work Ready, or KEYS Name
Address Line 1
Address Line 2
City, State, Zip
FAX: (555) 555-555
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Community Service Volunteer Verification Form (Lehigh Carbon Community College)

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Completed 4 February 2021

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