Verification Of Caretaker Or Companionship Services - Dcf-Economic Services Division
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1Vermont Department for Children and Families
Economic Services Division
Verification of Caretaker or Companionship Services
Only the homeowner or head of household can qualify to have a live-in caretaker or companion excluded
from the household.
Date
Homeowner or head of household
Social security number
Person providing caretaker or companion services
Social security number
Please answer the questions below and return this form to the Office of Home Heating Fuel Assistance within
10 days. If you have questions, please call the Benefit Service Center at 1-800-479-6151.
1)
Please list the services your caretaker or companion provides and how often.
2)
Would you be able to live at home if your caretaker or companion did not provide these services for
you?
Yes
No
3)
Do you pay your caretaker or companion for these services?
Yes
No
If yes, how much? $
How often? __________________
4)
How long has your caretaker or companion lived with you and provided these services?
number of weeks, months, or years
Applicant signature
Date
Caretaker or companion signature
Date
Return this form to: DCF-Economic Services Division
Application and Document Processing Center
280 State Drive
Waterbury VT 05671-1500
Revised 10/2015
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