GA-TANF Diaper Project Form

GA-TANF Diaper Project Form
This form is for TANF-enrolled households. Applicants must submit a TANF Enrollment Letter or TANF Notice of Recertification dated within the last 12 months containing the names of the children needing diapers.

All children enrolled in this GA-TANF Diaper Project will receive an entire 4 month supply of diapers and/or pull-ups. You will select diaper sizes for each of the 4 months.

Up to 4 children can be included on this form. If there are additional children in the household that need diapers, please submit an additional form.

Please Note: These diapers and pull-ups are for individual use and not for resale.

Please email tanf@helpingmamas.org with any questions.
Name of Head of Household*

First NameLast Name
Current address of Head of Household*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:*
District*
Current Phone Number of Applicant*
Please enter a valid phone number.
Current Email of Applicant
example@example.com
TANF Case Number
TANF Case Manager
Instructions for Finding TANF Acceptance Letter in Gateway:

1. Go to Gateway website and click on “Apply For or Renew Benefits” (not login)

2. Log into your account

3. Scroll to menu at bottom of page (options)

4. Check Medicaid, Food Stamps, and TANF

5. Click on “My Notices” then “Medical Assistance”

6. Add the dates within the last year from today’s date (Ex; 4/20/22-4/20/23)

7. Go through each notice to find the one with the TANF notice

8. When going through the notices, look at Eligibility, Determination, and Changes
Method to provide TANF Enrollment Letter (complete letter including list of children required)*

Photo Start
Take a photo of TANF Enrollment Letter (Complete letter including list of children required)*

Upload
Upload TANF Enrollment Letter (complete letter including list of children required). Letter must be dated within the last 12 months and must contain the names of the children diapers are being requested for.*

Cancelof

Child 1 Start
Child #1:
Name of Child #1 requesting diapers*

First NameLast Name
Child #1 age*
Child #1 gender*
Child #1 race/ethnicity*
Child #1: Select a diaper size for each month of service (1 month = 300 diapers)
DIAPER SIZE CHART
Month 1:(approx. 300 diapers/month)*
Month 2:(approx. 300 diapers/month)*
Month 3:(approx. 300 diapers/month)*
Month 4:(approx. 300 diapers/month)*
Is there another Child in this household needing diapers?*

YesNo

Child 1 End

Child 2 Start
Child #2:
Name of Child #2 requesting diapers*

First NameLast Name
Child #2 age*
Child #2 gender*
Child #2 race/ethnicity*
Child #2: Select a diaper size for each month of service (1 month = 300 diapers)
DIAPER SIZE CHART
Month 1:(approx. 300 diapers/month)*
Month 2:(approx. 300 diapers/month)*
Month 3:(approx. 300 diapers/month)*
Month 4:(approx. 300 diapers/month)*
Is there another Child in this household needing diapers?*

YesNo

Child 2 End

Child 3 Start
Child #3:
Name of Child #3 requesting diapers*

First NameLast Name
Child #3 age*
Child #3 gender*
Child #3 race/ethnicity*
Child #3: Select a diaper size for each month of service (1 month = 300 diapers)
DIAPER SIZE CHART
Month 1:(approx. 300 diapers/month)*
Month 2:(approx. 300 diapers/month)*
Month 3:(approx. 300 diapers/month)*
Month 4:(approx. 300 diapers/month)*
Is there another Child in this household needing diapers?*

YesNo

Child 3 End

Child 4 Start
Child #4:
DIAPER SIZE CHART
Name of Child #4 requesting diapers*

First NameLast Name
Child #4 age*
Child #4 gender*
Child #4 race/ethnicity*
Child #4: Select a diaper size for each month of service (1 month = 300 diapers)
Month 1:(approx. 300 diapers/month)*
Month 2:(approx. 300 diapers/month)*
Month 3:(approx. 300 diapers/month)*
Month 4:(approx. 300 diapers/month)*

Child 4 End
I certify that the information shown above is true and accurate to the best of my knowledge.*

I agree - Check this box and sign below if you are the applicantI agree - Check this box and sign below if you are filling out the form on behalf of the Applicant.
Signature*

Clear

Counter

	Newborn	Size 1	Size 2	Size 3	Size 4	Size 5	Size 6	2T-3T	3T-4T	4T-5T
Month1A
Month1B
Month1C
Month1D
Month2A
Month2B
Month2C
Month2D
Month3A
Month3B
Month3C
Month3D
Month4A
Month4B
Month4C
Month4D

Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
Size 6
2T-3T
3T-4T
4T-5T
Should be Empty:

GA-TANF Diaper Project Form

Child #1:

Child #1: Select a diaper size for each month of service (1 month = 300 diapers)

Child #2:

Child #2: Select a diaper size for each month of service (1 month = 300 diapers)

Child #3:

Child #3: Select a diaper size for each month of service (1 month = 300 diapers)

Child #4:

Child #4: Select a diaper size for each month of service (1 month = 300 diapers)