State of Tennessee

Tennessee Dept. of Human Services Out of State Inquiry Form

THIS FORM IS FOR STATE AGENCY USE ONLY

For Out of State agencies to verify a customer's benefits received through the Tennessee Department of Human Services, please use the form below as the perferred method of contact. If you are unable to use the form, a request may be faxed to the Out of State Inquiry Unit at 615-687-5535.

Please allow 3 business days for a response.

Requestor's Name*

First Name

Last Name

Agency Name*

Address*

E-mail*

Confirm E-mail *

Phone*

Fax*

Type of Inquiry*

Out of State PARIS Match

Customer's Date of Application

Customer's Current Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Comments/Brief Narrative*

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What is 9 minus 4*

Christmas falls on December*