Ala. Admin. Code r. 660-1-4-B
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Aid to Families With Dependent Children
FORM LAST
NUMBER REVISION FORM TITLE
DHR-OFAO Taxpayer Notice of Tax Refund Intercept
PB-FORM-203B Jul. 88Victim's Impact Statement
RPT-391 Nov. 84ADC Potential Terminations/Deletions
DHR-PAD Aug. 89Work and Training Communication Forms
PSD-BPA-569 Oct. 79Transmittal Referral for Child Support Activities
PSD-BPA-595 Oct. 90ADC Summarized Eligibility Requirements
DHR-PAD-600 Oct. 89Cooperation in Child Support and/or the Pursuit of Third Parties Liability for Medical Services
PSD-BPA-601 Aug. 84Application for Exception to Cooperation in Child Support
PSD-BPA-602 Aug. 84Notice of Good Cause Decision
PSD-BPA-603 May 79Affidavit (Regarding Good Cause)
PSD-BPA-604 May 79Request for Information/Documentation
PSD-BPA-638 June 66Farm Income Report
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial or Pending Action
PSD-BPA-668 Dec. 81Social Information Report
DHR-PAD-670 Apr. 88Notice of PA Case Transfer
PSD-BGM-677 June 80Affidavit (Regarding Lost/Stolen Warrants)
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank/Clearance
DHR-PAD-690 Apr. 90Application/Redetermination For Aid
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-709 Sep. 75Agreement Between PSD and
Substitute Payee
PSD-BPA-746 Nov. 76Record of Contact
DHR-PAD-752 June 88Request for Unemployment
Compensation Benefits
DHR-PAD-770 Aug. 89ADC Incapacity Determination
PSD-BPA-773 Jan. 83Referral to Vocational
Rehabilitation Services
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BPA-826 July 80Claims Report
PSD-BFM-829 July 81Check Inquiry
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding Lost/Stolen Warrants)
PSD-PAD-1267 Apr. 90Public Assistance Trial Budget Worksheet
DHR-PAD-1286 Mar. 90Redetermination for Financial/Medical or Medical Assistance
PSD-BPA-1310 Jan. 86Monthly ADC Report
PSD-BPA-1317 Mar. 82Notice of Decision/Combined Notice of Action
DHR-PAD-1318 Oct. 90Certification of Medicaid Eligibility
PSD-BPA-1319 Mar. 82PARS Error Control Form
PSD-BPA-1320 Mar. 82Hold and Disposition
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Data Turnaround Document (TAD)
PSD-BPA-1323 Sep. 83Additional Client Record
DHR-PAD-1328 Jan. 87Public Assistance Case Review Checklist - ADC
PSD-BPA-1333 Apr. 85Case ID Change Form
PSD-BPA-1353 Oct. 82Authorization for Assistance for Prior Period of Eligibility
PSD-BPA-1376 Mar. 83Declaration of Natural Relationship
PSD-BPA-1380 June 82Notice of Incomplete Monthly ADC Report
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BPA-1417 July 84Absent Parent Record
PSD-BPA-1430 Sep. 84Application/Screening Form
PSD-BPA-1438 Nov. 84Notice Letter for Repayment
PSD-BPA-1440 Nov. 84Notice of Delinquent Payment
PSD-BPA-1441 Oct. 84Agreement to Sell Real Property
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
DHR-PAD-1512 Jan. 87Public Assistance Case Review Summary-ADC
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1531 Sep. 86IEVS Verification/ Investigation Update
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 87Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
DHR-OFA-1562 Mar. 88Repayment Agreement
DHR-PAD-1603 Nov. 88Notice of AFDC Fraud Control Program
DHR-PAD-1625 Oct. 89Grantee Failure to Cooperate in Third Party Medical Liability Activities
DHR-PAD-1660 Jun. 90Transitional Child Care (TCC) Notice
DHR-PAD-1661 Apr. 90Transitional Medicaid Notice
and Three-Month Report
DHR-PAD-1662 Apr. 90Notice of Incomplete Three- Month Report
PSD-BPA-MR-B June 82Brochure on Monthly Reporting
PSD-BPA-MR-D June 82Notice of Termination Due to Failure to Send in Timely Monthly Report
PSD-BPA-MR-F June 82Notice to Reapply
Federal Forms Used by the Division
FORM LAST
NUMBER REVISION FORM TITLE
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 Jun. 81Report on New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Foster Care Maintenance Payments
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial or Pending Action
PSD-BPA-668 Dec. 81Social Information Report
DHR-PAD-670 Apr. 88Notice of PA Case Transfer
PSD-BFM-673 Dec. 79Address Change Mailing Slip
PSD-BFM-674 Nov. 81Hold Order and/or Disposition Advice
PSD-BFM-677 June 80Affidavit (Regarding Lost/ Stolen Warrants)
PSD-BFM-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
PSD-BPA-690 Mar. 86Application/Redetermination for Aid
PSD-BPA-699 Mar. 66Consent of DPS to Appointment of Legal Representative
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
PSD-BPA-755 July 82Eligibility for FCMP/ACFC Medicaid
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BPA-826 July 80Claims Report
PSD-BGM-829 July 81Check Inquiry
PSD-BPA-969 Oct. 81Public Assistance Eligibility Data
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding Lost/Stolen Warrants)
PSD-BPA-
PSD-BPA-1376 Mar. 83Declaration of Natural Relationship
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1532 Sep. 86Verification of Wages
Federal Forms Used by the Division
SSS-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information in Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Aid to Refugees
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial or Pending Action
DHR-PAD-670 Apr. 88Transfer Agreement Notice of
PA Case Transfer
PSD-BFM-677 June 80Affidavit (Regarding Lost/ Stolen Warrants)
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
PSD-BPA-690 Nov. 88Application/Redetermination for Aid
PSD-BPA-699 Mar. 66Consent of DPS to Appointment of Legal Representative
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
DHR-PAD-752 June 75Information Concerning Request for Unemployment Compensation Benefits
DHR-PAD-770 Aug. 89ADC Incapacity Determination
PSD-BPA-773 Jan. 83Referral to Vocational Rehabilitation Services
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BPA-826 July 80Claims Report
PSD-BFM-829 July 81Check Inquiry
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding Lost/Stolen Warrants)
PSD-PAD-1267 Apr. 90Public Assistance Trial Budget Worksheet
PSD-BPA-1270 Oct. 81Earned Income Credits Payment Checklist
PSD-BPA-1310 Jan. 86Monthly ADC Report
PSD-BPA-1317 Mar. 82Notice of Decision/Combined Notice of Action
DHR-PAD-1318 Oct. 90Certification of Medicaid Eligibility
PSD-BPA-1319 Mar. 82PARS Error Control Form
PSD-BPA-1320 Mar. 82Hold and Disposition
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Data Turnaround Document (TAD)
PSD-BPA-1323 Sep. 83Additional Client Record
PSD-BPA-1333 Apr. 85Case ID Change Form
PSD-BPA-1353 Oct. 82Authorization For Assistance For Prior Period Of Eligibility
PSD-BPA-1380 June 82Notice of Incomplete Monthly ADC Report
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BPA-1430 Sep. 84Application/Screening Form
PSD-BPA-1438 Nov. 84Notice Letter For Repayment
PSD-BPA-1440 Nov. 84Notice of Delinquent Payment
PSD-BPA-1441 Oct. 84Agreement to Sell Real Property
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1531 Sep. 86IEVS Verification/Investigation Update
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 86Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
PSD-BPA-MR-B June 82Brochure on Monthly Reporting
PSD-BPA-MR-D June 82Notice of Termination Due to Failure to Send in Timely Monthly Report
PSD-BPA-MR-F June 82Notice to Reapply
Federal Forms Used by the Division
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Aid to the Blind
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-556 June 78Physician's Report of Eye Examination
PSD-BPA-597 Jan. 86Aid to Blind Summarized Eligibility Requirements
DHR-PAD-640 Feb. 90Supplementation Budget
DHR-PAD-641 Feb. 90Supplementation Budget For Deeming Parents to Children
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial or Pending Action
DHR-PAD-670 Apr. 88Notice of PA Case Transfer
PSD-BPA-672 June 78Optometrist's Report on Eye Examination
PSD-BFM-677 June 80Affidavit (Regarding Lost/Stolen Warrants)
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
PSD-BPA-693 Apr. 85Application Review Form - Supplementation
PSD-BPA-694 Sep. 79Statement of Income/Resources- Supplementation
PSD-BPA-696 Feb. 85Physician's Recommendation (Regarding Nursing Or Attendant Care)
PSD-BPA-699 Mar. 66Consent of DPS to Appointment of Legal Representative
PSD-BPA-700 Mar. 66Physician's Certification For Legal Representative
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
PSD-BPA-797 Nov. 81Agreement to Provide Personal Care
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BPA-826 July 80Claims Report
PSD-BFM-829 July 81Check Inquiry
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding
Lost/Stolen Warrants)
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Turnaround Document (TAD)
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BPA-1438 Nov. 84Notice Letter For Repayment
PSD-BPA-1440 Nov. 84Notice Of Delinquent Payment
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 87Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
DHR-PAD-1602 Jan. 89Application/Redetermination For QMB
Federal Forms Used by the Division
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Aid to the Permanently and Totally Disabled
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-598 Jan. 86APTD Summarized Eligibility Requirements
PSD-PAD-640 Feb. 90Supplementation Budget
PSD-PAD-641 Feb. 90Supplementation Budget for Deeming Parents to Children
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-660 Apr. 85Notice of Denial Or Pending Action
PSD-BPA-667 July 86Report of Physician's Examination
PSD-BPA-668 July 86Social Information Report
DHR-PAD-670 Apr. 88Notice of PA Case Transfer
PSD-BFM-677 June 80Affidavit (Regarding Lost/ Stolen Warrants)
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
PSD-BPA-693 Apr. 85Application Review Form - Supplementation
PSD-BSA-694 Sep. 79Statement of Income/Resources- Supplementation
PSD-BPA-696 Feb. 85Physician's Recommendation (Regarding Nursing or Attendant Care)
PSD-BPA-699 Mar. 66Consent to DPS to Appointment of Legal Representative
PSD-BPA-700 Mar. 66Physician's Certification for Legal Representative
PB-FORM-203B Jul. 88Victim's Impact Statement
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
PSD-BPA-773 Jan. 83Referral to Vocational Rehabilitation Service
PSD-BPA-797 Nov. 81Agreement to Provide Personal Care
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BFA-826 July 80Claims Report
PSD-BFM-829 July 81Check Inquiry
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding Lost/Stolen Warrants)
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Turnaround Document (TAD)
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BPA-1438 Nov. 84Notice Letter For Repayment
PSD-BPA-1440 Nov. 84Notice of Delinquent Payment
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 87Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
DHR-OFA-1562 Mar. 88Repayment Agreement
DHR-PAD-1602 Jan. 89Application/Redetermination for QMB
Federal Forms Used by the Division
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Reserved
FORM LAST
NUMBER REVISION FORM TITLE
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Medicaid Eligibility
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial or Pending Action
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
DHR-PAD-690 Apr. 90Application/Redetermination for Aid
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
DHR-PAD-752 June 88Request for Unemployment Compensation Benefits
PSD-BPA-799 Feb. 78Communication Memo
PSD-BPA-969 Oct. 81Public Assistance Eligibility Data
PSD-BPA-1132 Dec. 85Required Verification
DHR-PAD-1267 Apr. 90Public Assistance Trial Budget Worksheet
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Turnaround Document (TAD)
PSD-BPA-1323 Sep. 83Additional Client Record
PSD-BPA-1330 June 82EPSDT Referral (Adult Only)
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
DHR-PAD-1480 Oct. 90Medicaid for Pregnant Women and Young Children Meeting
AFDC Income and Resource Standards Summarized Eligibility Requirements
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1531 Sep. 86IEVS Verification/Investigation Update
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 87Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
DHR-PAD-1581 July 88Presumptive Eligibility Medicaid Card
Federal Forms Used by the Division
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Old Age Pension
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-596 Jan. 86Old Age Pension Summarized Eligibility Requirements
DHR-PAD-640 Feb. 90Supplementation Budget
DHR-PAD-641 Feb. 90Supplementation Budget For Deeming Parents to Children
PSD-BFC-650 Aug. 65Vital Statistics Verification
PSD-BPA-657 July 83Notice of Action
PSD-BPA-660 Apr. 85Notice of Denial of Pending Action
PSD-BFC-670 Apr. 88Notice of PA Case Transfer
PSD-BFM-677 June 80Affidavit (Regarding Lost/Stolen Warrants)
PSD-BSA-686 May 80Interview Notification
PSD-BFA-689 Sep. 86Bank Clearance
PSD-BPA-693 Apr. 85Application Review Form - Supplementation
PSD-BPA-694 Sep. 79Statement of Income/
Resources - Supplementation
PSD-BPA-696 Feb. 85Physician's Recommendation (Regarding Nursing or Attendant Care)
PSD-BPA-699 Mar. 66Consent of DPS to Appointment of Legal Representative
PSD-BPA-700 Mar. 66Physician's Certification for Legal Representation
PSD-BPA-701 Nov. 88Release of Information
DHR-PAD-703 Apr. 88Client's Written Statement (Regarding Changes and Adverse Action)
PSD-BPA-746 Nov. 76Record of Contact
PSD-BPA-797 Nov. 81Agreement to Provide Personal Care
PSD-BPA-799 Feb. 78Communication Memo
PSD-DFD-818 Nov. 84Overpayment Form
PSD-BFA-826 July 80Claims Report
PSD-BFM-829 July 81Check Inquiry
PSD-BPA-1132 Dec. 85Required Verification
PSD-BPA-1233 July. 81Second Endorser Letter (Regarding Lost/Stolen Warrants)
PSD-BPA-1234 Apr. 87Notice to Claimants (Regarding Lost/Stolen Warrants)
PSD-BPA-1321 Mar. 84Application Turnaround Document (TAD)
PSD-BPA-1322 Mar. 84Payee/Case Turnaround Document (TAD)
PSD-BPA-1389 Aug. 83Out-of-State Inquiry
PSD-BPA-1438 Nov. 84Notice Letter for Repayment
PSD-BPA-1440 Nov. 84Notice of Delinquent Payment
PSD-BPA-1487 Aug. 85Wage/Unemployment Compensation Online Request
PSD-BPA-1513 June 86Public Assistance Case Review Checklist-SUP
PSD-BPA-1514 June 86Public Assistance Case Review Summary-SUP
PSD-BCS-1515 Jan. 86Medical Support Information
DHR-PAD-1532 Sep. 86Verification of Wages
DHR-PAD-1534 Sep. 86IEVS Action Request
DHR-PAD-1535 Sep. 86IEVS Client Data
DHR-PAD-1542 Feb. 87Referral for SS-5
DHR-PAD-1546 Apr. 87Verification of Social Security Number
DHR-PAD-1602 Jan. 89Application/Redetermination for QMB
Federal Forms Used by the Division
SSA-491TC Feb. 85Third Party Query Card
SSA-1610 Feb. 72Social Security Information and Report
SSA-8150 May 78Report of New Information In Supplemental Security Income Claims
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: 2.2% Energy Credit Program
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-1263 Oct. 812.2 Summarized Eligibility Requirements
PSD-BPA-1264 Oct. 812.2 Electric Exemption Program Application
PSD-BPA-1266 Oct. 812.2 Electric Exemption Program Transmittal
PSD-BPA-1276 Oct. 812.2 Electric Exemption Program Quarterly Report of Benefits
APPENDIX B - DEPARTMENTAL FORMS INDEX
Economic Assistance Division
Program/Service: Office of Work and Training Services
FORM LAST
NUMBER REVISION FORM TITLE
DHR-PAD-535 Aug. 89Work and Training Communication Memo
DHR-PAD-1607 Aug. 89ADC Employment and Training
APPENDIX B - DEPARTMENTAL FORMS INDEX
Child Support Division
Program/Service: Child Support
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BCS-567 Nov. 81Absent Parent Fact Sheet
PSD-BCS-569 Oct. 79Transmittal of Referral for Child Support Activities
PSD-BCS-570 Jan. 82Application for Child Support Services
PSD-BCS-571 Apr. 81Maintenance Batch Header
PSD-BCS-572 Oct. 82SPLS Location Request
PSD-BCS-574 Dec. 81Notification and Transfer Form
PSD-BCS-576 Dec. 81Paternity Acknowledgement
PSD-BCS-577 Mar. 78Notice of Prosecuting Attorney
PSD-BCS-578 Aug. 81Cash Correction
PSD-BCS-579 Mar. 79Notice of Prosecuting Attorney-Good Cause Determination
PSD-BCS-580 Aug. 81Employer Letter--County
PSD-BCS-581 Feb. 82Case Summary/Child Summary
PSD-BCS-582 Aug. 84Postmaster Letter--County
PSD-BCS-583 May 79Key Change Input Form
PSD-BCS-584 June 77Memo--Grantee Refusal to Cooperate
PSD-BCA-586 Dec. 82Notice to Terminate Collection
PSD-BCS-587 Mar. 77IV-D Child Support Time Log
PSD-BCS-588 Mar. 77Affidavit of Mother
PSD-BCS-589 Oct. 85Report of Child Support Enforcement Activities Under Title IV-D
PSD-BCS-591 Dec. 82Request for Interview
PSD-BCS-592 May 79URESA Form Letter
PSD-BCS-692 Oct. 82Public Safety Information Request
PSD-BCS-905 Dec. 78Alabama Child Support Cash Remittance
PSD-BCS-946 Alabama Child Support Case Document
PSD-BCS-1232 July 81Child Support Interview Appointment Letter
PSD-BCS-1243 July 85Tax Offset-Child Support Arrearage Certification
PSD-BCS-1253 Aug. 82Employer Information Request
PSD-BCS-1273 Sep. 81Locate Request To Unemployment Compensation Office
PSD-BCS-1289 Nov. 81Child Support Second Interview Appointment Letter
PSD-BCS-1304 Jan. 82Notice to Collect
PSD-BCS-1313 Feb. 82Taxpayer Notice of Tax Refund Offset
PSD-BCS-1356 Nov. 86Reimbursement Request for Child Support Activities
PSD-BCS-1378 Apr. 83Daily Time Log (Private Attorney)
PSD-BCS-1383 SPLS Prisoner Locate Letter
PSD-BCS-1392 Apr. 83Adjustment to Child Support Arrearage
PSD-BCS-1393 Arrearage Calculation Worksheet
PSD-BCS-1394 Oct. 83SPLS County Return Letter
PSD-BCS-1400 Dec. 83Information for Absent Parents Under Child Support Order
PSD-BCS-1410 Absent Parent File Folders (Orange)
PSD-BCS-1432 July 84Financial Assessment Questionnaire
PSD-BCS-1442 July 84Financial Assessment Transmittal Letter
PSD-BCS-1447 Jan. 85Adjusted Taxpayer Notice of Tax Refund Offset
PSD-BCS-1461 May 85Affidavit Of Past Due Support
PSD-BCS-1462 May 85Tax Refund Intercept Agreement
PSD-BCS-1464 June 85Notice of Termination and/or Change in Status of Child Support Services
PSD-BCS-1465 June 85Transmittal of Child Support Fees and Miscellaneous Reimbursements
PSD-BCS-1489 Aug. 85Alabama Child Support Non-Cash Collection Report
PSD-BCS-1490 Oct. 85Report of Five Month Arrearage Collections
PSD-BCS-1491 Sep. 85Declaratory Statement of Income for Determination of Non-ADC Application Fee
(Rev. 5-1-86)
PSD-BCS-1492 July 85Request for Update of Tax Offset Transmittal
PSD-BCS-1515 Jan. 86Medical Support Information
PSD-BCS-1516 Jan. 86Notice/Report to Consumer Reporting Agency
PSD-BCS-1517 Jan. 86Notice of Intent to Release Child Support Debt Information
DHR-CSD-1541 Dec. 86SPLS Response Form
DHR-CSD-1543 May 89Agreement for Withholding Unemployment Compensation
DHR-CSD-1544 May 89Authorization for Department of Industrial Relations to Withhold Unemployment Benefits
DHR-CSD-1614 Mar. 89Interstate Communications Memorandum
DHR-CSD-1626 May 89Receipt - Child Support Program
DHR-CSD-1627 May 89Address Form - Unemployment Compensation Case Information
DHR-CSD-1752 Oct. 90Notices for Right to Review of Child Support Court Order
DHR-CSD-1753 Oct. 90Notice of Scheduled Review of Child Support Court Order
DHR-CSD-1754 Oct. 90Notice of Results of Review of Child Support Order
APPENDIX B - DEPARTMENTAL FORMS INDEX
Food Stamp Division
Program/Service: Food Stamps
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-110 May 80Interview Notification
PSD-BFA-501 May 83Notice of County Department
Administration Fraud Hearing Action
PSPWB525A Oct. 85Automated Referrals from PARS (Code Sheet)
DHR-FSD-657 Jul. 83Notice of Action
DHR-FSD-660 Apr. 85Notice of Denial or Pending Action
DHR-FSD-689 Sep. 86Bank Clearance
DHR-FSD-690 Oct. 79Application/Redetermination for Aid
DHR-PAD-752 June 88Unemployment Compensation
DHR-FSD-832 Sep. 81Alabama Food Stamp Identification Card
DHR-FSD-839 Mar. 79Income From Farm Operation
DHR-FSD-840 Oct. 83Income from Self-Employment (Other Than Farming)
DHR-FSD-841 Dec. 83Irregular Work Form
DHR-FSD-845 Dec. 82Change Report Form
DHR-FSD-854 Mar. 79Notice of Restoration of Benefits
PSD-BFA-856 May 83Repayments Agreement for Overissuance
DHR-FSD-858 May 86Verification of Income
DHR-FSD-859 Nov. 83Notice of Continuance
DHR-FSD-860 Mar. 79Verification of Farm Supplement
PSD-BFA-861 May 83Demand Letter for Overissuance
DHR-FSD-863 Nov. 83Authorization Form for A Household Representative
DHR-FSD-865 Mar. 79Request for a Fair Hearing
DHR-FSD-875 Nov. 89Student Verification Form
DHR-FSD-879 Oct. 81Notice of Expiration
DHR-FSD-958 Jan. 81Request for Additional Information
PSD-BFA-1040 May 83Notice of Existence of Non- Fraud Claim
PSD-BFA-1045 Oct. 82Authorization to Participate (ATP) Card
PSD-BFA-1048 May 83Advance Notice of Disqualification Hearing
DHR-FSD-1133 June 81Procedures for Registering Complaints and Suggestions
DHR-FSD-1134 May 81Notice of Discrimination Complaint
DHR-FSD-1141 July 83Application for Food Stamps
DHR-FSD-1241 Aug. 81Notice of Expiration
DHR-FSD-1242 Aug. 81Notice of Award
DHR-FSD-1309 Jan. 82Food Stamp Appointment Card
PSD-BPA-1310 June 83Monthly Report/Supplement
DHR-FSD-1329 Sep. 82Authorization For Participation Outside Normal Issuance Cycle
DHR-FSD-1334 July 82Affidavit of Loss-Food Stamp Program
DHR-FSD-1380 Sep. 89Notice of Incomplete Monthly Report
DHR-FSD-1385 May 83Waiver of Disqualification Hearing
PSD-BFA-1386 May 83Notice of Delinquent Payment
DHR-FSD-1399 Dec. 83Notice of Requirement to Monthly Report
DHR-FSD-1418 July 85Responsibilities and Penalties
DHR-FSD-1434 Sep. 89Monthly Report
DHR-FSD-1457 Nov. 85Collateral Form
DHR-FSD-1504 Nov. 85Reference Form
DHR-FSD-1507 Nov. 85Telephone Report of Change
DHR-FSD-1532 Unknown Verification of Wages
DHR-FSD-1590 Oct. 88Declaration of Citizenship/Alien Status
DHR-FSD-1629 Sep. 89Notice of Missing Information
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Adoption Services
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BFC-621 Mar. 84Report to the Court
DHR-DFC-623 Aug. 88Child's Medical Record-Foster Care
DHR-DFC-634 Mar. 87Physical Examination For
Prospective Adoptive Parents
PSD-BFC-643 Feb. 79Consent-State DPS to Adopt
PSD-BSA-686 Nov. 83Interview Notification
PSD-BFC-704 Oct. 81Application to Adopt a Child
PSD-BFC-705 Jan. 84Financial Statement
PSD-BFC-706 Jan. 84Information Regarding Immediate Relatives
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application for Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request for More Information
PSD-OSS-765 Consent Form for Release of Information
PSD-BFC-777 Child's Development Record
PSD-BFC-782 Child's Record
PSD-BFC-822 Dec. 79Adoption Subsidy Agreement
PSD-BFC-911 Sep. 80Registration of Waiting Child
PSD-BFC-912 Sep. 80Notice of Inquiry
PSD-BFC-913 Sep. 80Notice of Placement Change or Hold
PSD-BFC-951 Jan. 81Adoption Subsidy Recertification
PSD-BFC-1299 Dec. 81Desired Child
PSD-BFC-1300 Jan. 84Knowing Myself
PSD-BFC-1301 Jan. 84Starting to Look at My Values Adoptive Home Placement Agreement
DHR-DFC-1748 Jan. 91Child's Medical History
DHR-DFC-1749 Jan. 91Medical History of Biological Parent
DHR-DFC-1750 Jan. 91Report of Release
DHR-DFC-1751 Jan. 91Pre-Placement Report
DHR-DFC-1755 Jan. 91Relinquishment of Minor for Adoption
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Day Care for Adults
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-664 May 81Report of Physician's Examination of Day Care/Foster
Care Adults
PSD-BSA-686 Aug. 78Interview Notification
PSD-BSA-733 Aug. 74Application to Provide Home Day Care for Adults
PSD-OSS-757 Oct. 82Fact Sheet
PSD-OSS-758 Sep. 80Application for Services
PSD-OSS-761 Sep. 80Notice of Action Taken on Services
PSD-OSS-764 Request for More Information
PSD-OSS-765 Consent Form
PSD-OSS-971 Feb. 81Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Day Care for Children
FORM LAST
NUMBER REVISION FORM TITLE
DHR-DFC-624 July 88Child's Medical Report - Day Care
DHR-DFC-644 June 88Monthly Report - Day Care/Night-Time Home for Children
DHR-DFC-645 Oct. 88Monthly Report (Day Care Center)
PSD-BSA-686 Aug. 78Interview Notification
DHR-DFC-712 July 88Application for a License to Give Care to Children
DHR-DFC-713 Mar. 87License to Operate Child Care Facility
DHR-OCG-724 Oct. 86Purchase of Services Authorization
DHR-DFC-737 July 88Medical Report for Persons Giving Care to Children
DHR-DFC-738 Mar. 87Six-Month Permit
DHR-DFC-739 June 88Child's Pre-Admission Record
DHR-DFC-740 July 88Application for License to Conduct Child Care Facility
DHR-DFC-742 July 88Information Form for Licensing Study - Day/Night Care Center
DHR-DFC-743 Mar. 87License-Child Care Facilities
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application for Services
DHR-761 Jan. 90Notice of Action Taken On Services
DHR-764 Jan. 90Request for More Information
PSD-OSS-765 Consent Form
PSD-DSP-920 Mar. 83Request for Day Care Payment
PSD-BPA-969 Oct. 81Public Assistance Eligibility Data
PSD-OSS-971 Feb. 81Service Agreement
PSD-DSP-1222 Sep. 81Notice of Errors in Request for Day Care Payment
DHR-OCG-1407 Jan. 90Fee Assessment/Agreement
PSD-DSP-1408 May 84Monthly Summary of Day Care Fees
PSD-DSP-1411 May 84Notice of Delinquent Fees for Day Care Services
PSD-DSP-1427 Chronic Absenteeism Reporting Form
DHR-DFC-1585 June 88Probationary Permit
DHR-1664 April 90Self-Arranged Child Care
DHR-WR-1708 June 90Day Care Reimbursement Receipt
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Emergency Welfare Services
FORM LAST
NUMBER REVISION FORM TITLE
PSD-DEW-523 Mar. 77Referral Form
PSD-DEW-527 Mar. 77Registration and Information Record
PSD-DEW-528 Mar. 77Registration and Information Record (Continued)
PSD-DEW-529 Sep. 74On-Site Welfare Center Referral
DHR Pamphlet June 88EWS Information (Pamphlet) Series (74-1)
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Foster Care for Adults
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-664 May 81Report of Physician's Examination of Day Care/Foster
Care Adults
PSD-BSA-663 Jan. 73Application to Provide Foster Care for Adults
PSD-BSA-686 Aug 78Interview Notification
PSD-OSS-757 Oct. 82Fact Sheet
PSD-OSS-758 Sep. 80Application for Services
PSD-OSS-761 Sep. 80Notice of Action Taken on Services
PSD-OSS-764 Request for More Information
PSD-OSS-765 Consent Form
PSD-OSS-971 Feb. 81Service Agreement
PSD-BSA-1332 Jun. 82Adult Foster Care Payment Contract
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Foster Care for Children
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BPA-556 June 78Physician's Report on Eye Examination
DHR-BFC-610 Jan. 83Monthly Population Report of Child Care Facilities
DHR-BFC-611 July 88Monthly Report of Children Under Care or Supervision of
Licensed Child Placing Agencies
DHR-DFC-612 July 88Application to Operate Foster Family Home
DHR-DFC-614 Mar. 87Foster Family Home Approval
DHR-615 Aug. 90Related Family Home Approval
DHR-DFC-623 Aug. 88Child's Medical Record-Foster Care
PSD-BPA-667 July 79Report of Physician's Examination
PSD-BPA-672 June 78Optometrist's Report on Eye Examination
PSD-BSA-686 Aug. 78Interview Notification
PSD-BPA-693 Apr. 85Application -- Review Form - Supplementation
PSD-BPA-694 Sep. 79Statement of Income/Resources Supplementation
PSD-BPA-696 Feb. 85Physician's Recommendation (Regarding Nursing Or Attendant Care)
DHR-PAD-703 Apr. 88Client's Written Statement Regarding Changes and Adverse Action
DHR-OCG-724 Oct. 86Purchase of Services Authorization
DHR-DFC-731 Nov. 87Agreement for Foster Care
DHR-DFC-735 July 88Child Placing Agency Approval
DHR-DFC-736 July 88Financial Report
DHR-DFC-737 July 88Medical Report for Persons Giving Care to Children
DHR-DFC-738 Mar. 87Six Month Permit
DHR-DFC-740 July 88Application For License To
Conduct Child Care Facility
DHR-DFC-741 July 88Information Form for Licensing Study - Child Care Institution
DHR-DFC-743 Mar. 87License-Child Care Facilities
PSD-BFC-750 County Department/Agency Placing Agreement
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application for Services
DHR-761 Jan. 90Notice of Action Taken On Services
DHR-764 Jan. 90Request For More Information
PSD-OSS-765 June 84Consent Form
PSD-BFC-775 Foster Parent Identification Card
PSD-BFC-777 Child's Development Record
PSD-BFC-782 Child's Record
DHR-807 Aug. 90Long-Term Foster Care Agreement
DHR-DFC-809 July 88Child's Record Sheet For Shelter Care Facility
DHR-DFC-823 July 88Inter-Agency Agreement
DHR-DFC-824 July 88Placement Agreement
PSD-BFC-1330 Aug. 84EPSDT Services
PSD-DSP-1450 Feb. 85Authorization For D & E/MHC Services
PSD-DFC-1569 For the School Age Child
DHR-DFC-1585 June 88Probationary Permit
DHR-DFC-1606 Apr. 90Unrelated Visitation Resource Approval
DHR-DFC-1624 Feb. 89Independent Living Assessment/Case Plan
DHR-1668 Aug. 90Foster Parent Compensation as Co-Trainer
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Homemaker Services for Adults
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
PSD-OSS-757 Oct. 82Fact Sheet
PSD-OSS-758 Sep. 80Application For Services
PSD-OSS-761 Sep. 80Notice of Action Taken on Services
PSD-OSS-764 Requests For More Information
PSD-OSS-765 Consent Form
PSD-BSA-821 Feb. 80Homemaker Service Contract
PSD-OSS-971 Feb. 81Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Homemaker Services for Children
FORM LAST
NUMBER REVISION FORM TITLE
PSD-OSS-720 Department of Pensions and Security Health Certificate
PSD-BSA-686 Aug. 78Interview Notification
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application for Services
DHR-761 Jan. 90Notice of Action Taken On Services
DHR-764 Jan. 90Request for More Information
PSD-OSS-765 June 84Consent Form
PSD-BFC-800 Mar. 78Agreement For the Provision of Homemaker Services For Children
PSD-BFC-963 Feb. 81Homemaker Referral Form
DHR-971 Jan. 90Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Individual and Family Grant Program
FORM LAST
NUMBER REVISION FORM TITLE
PSD-DEW-509 Jan. 87Referral to State IFG Representative
PSD-DEW-511 Aug. 82Funeral Verification
PSD-DEW-513 July 82Agreement to Return Verification Pamphlet Series
88-6 Apr. 88Fact Sheet
PSD-DEW-522 Aug. 82Medical/Dental Verification
PSD-DFD-818 Nov. 84Overpayment Form
PSD-DEW-1131 Jan. 87Individual and Family Grant Record Checklist
PSD-DEW-1343 Aug. 82Cost of Estimates/Other Expenses Verification
PSD-DEW-1344 Aug. 82Flood Insurance Verification
PSD-DEW-1345 Aug. 82Flood Insurance Verification Letter No. 1
PSD-DEW-1346 Aug. 82Flood Insurance Verification Letter No. 2
DHR-OFA-1562 Mar. 88Repayment Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Preventive/Supportive Services
(Adult or Family and Children)
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application For Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request For More Information
PSD-OSS-765 June 84Consent Form
PSD-BSA-798 June 81Report of Adult Suspected To Be Abused, Neglected, or Exploited
DHR-971 Jan. 90Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Protective Services For Adults
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
PSD-OSS-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application For Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request For More Information
PSD-OSS-765 June 84Consent Form
PSD-BSA-798 June 81Report of Adult Suspected To Be Abused, Neglected, or Exploited
DHR-971 Jan. 90Service Agreement
PSD-BSA-1337 Jul. 82Agreement to Provide Emergency Shelter Care for Adults
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Protective Services For Children
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
DHR-DFC-731 Nov. 87Agreement for Foster Care
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application For Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request For More Information
PSD-OSS-765 Consent Form
DHR-971 Jan. 90Service Agreement
PSD-BFC-1292 Dec. 81Agreement Referral To Parenting Education Classes
PSD-BFC-1293 Dec. 81Referral Form - Parent Education Project
PSD-DSP-1450 Feb. 85Authorization For D & E/MHC Services
DHR-1519 May 86Multi-Disciplinary Team Referral Form
DHR-1520 May 86Multi-Disciplinary Team Follow-up Report
DHR-DFC-1521 May 86Agreement on Confidentiality of Reports and Records of Child Abuse/Neglect
DHR-DFC-1522 May 86Child Abuse/Neglect Annual Multi-Disciplinary Team Report and Evaluation
DHR-DFC- 1591/1592 June 84Report of Suspected Case of Child Abuse/Neglect
DHR-DFC-1593 Written Report of Suspected Child Abuse/Neglect
DHR-DFC-1598 Request For Clearance of State Child Abuse/Neglect Central Registry
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Residential Care Services for
Delinquent Children and Youth
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application For Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request for More Information
PSD-OSS-765 June 84Consent Form
DHR-971 Jan. 90Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Residential Care Services for
Individuals With Exceptional Needs
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
DHR-OCG-724 Oct. 86Purchase of Services Authorization
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application For Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request for More Information
PSD-OSS-765 June 84Consent Form
DHR-971 Jan. 90Service Agreement
APPENDIX B - DEPARTMENTAL FORMS INDEX
Social Services Division
Program/Service: Transportation Services
(Adult or Family and Children)
FORM LAST
NUMBER REVISION FORM TITLE
PSD-BSA-686 Aug. 78Interview Notification
DHR-757 Apr. 90Fact Sheet
DHR-758 Jan. 90Application for Services
DHR-761 Jan. 90Notice of Action Taken on Services
DHR-764 Jan. 90Request For More Information
PSD-OSS-765 June 84Consent Form
DHR-971 Jan. 90Service Agreement