TANF Benefit Payment Issue Report Form

Full Name

First NameLast Name

Contact Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

TANF Case or Client ID (if known)

What type of payment issue are you experiencing?

Date the issue occurred or was noticed

Date

What was the expected payment amount?

How did you usually receive your TANF payments?

Other

Describe the payment issue in detail

Upload any supporting documents (optional)

Preferred method of contact for follow-up