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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

 

Purpose

Form 3067 is used to schedule an interview appointment, provide the household with examples of the type of information to bring to the interview and provide the household with information about their rights.

 

When to Prepare

Complete an original and one copy of Form 3067. Issue the original to the household and file the copy in the case record.

 

Form Retention

Maintain at least until the end of the third complete state fiscal year following the date on which Form 3067 is submitted.

 

Detailed Instructions

Client’s Name, Street Address, City, State and ZIP Code – Enter the client’s name, street address, city, state and ZIP code in the fields provided.

Date, Case Record No., Office Address and Area Code and Phone No. – Enter the date, case record number, office address and area code and phone number in the fields provided.

Check the appropriate box and enter the interview date, time and place in the fields provided.

Staff Signature and Area Code and Phone No. – Sign the form and provide the area code and phone number.