Alabama Administrative Code Chapter 660-1-4 — Forms

660 Alabama Department of Human Resources

Ala. Admin. Code r. 660-1-4-.01 Departmental Forms Index

(1) The Departmental Forms Index is hereby promulgated as a rule of the Department. The index, Appendix B, contains a listing of all forms used by the Department to inform and otherwise impart information to the public, to solicit, to gather, to verify, to certify and to record information required of and from the public by the various programs of the Department. Internal forms used for Departmental management, control, operations and communication are excluded from the index.

(2) Appendix A is provided to facilitate the use of the index. Appendix A includes:

(a) Abbreviations used in the index; and

(b) Organization of the index by Departmental divisions and program/service areas.

(3) The index will be updated on a calendar quarter basis.

History

• Authority: Code of Ala. 1975, § 41-22-4 (a)(2).
• Effective June 28, 1983.

Ala. Admin. Code r. 660-1-4-.02 Obtaining Copies Of Forms

(1) Single copies of forms may be obtained, without cost, by written request or contact with the State Office or main county offices of the Department.

(2) A list of internal forms excluded from the Departmental Forms Index and single copies therefrom may be obtained, without cost, by written request or contact with the State Office.

History

• Authority: Code of Ala. 1975, § 41-22-4(a)(2).
• Effective June 28, 1983.

Ala. Admin. Code r. 660-1-4-A Appendix A

APPENDIX A - DEPARTMENT FORMS INDEX

Abbreviations Used and Index Organization

A. Abbreviations Used

Abbreviation Meaning

ACFC Aid to Children in Foster Care

AFDC Aid to Families with Dependent Children

APTD Aid to the Permanently and Totally Disabled

ATP Authorization to Participate

CSED Child Support Enforcement Division

FSD Food Stamp Division

FCS Division of Family and Children's Services

FD Finance Division

PAD Public Assistance Division

ASD Adult Services Division

OCG Office of Contracts and Grants

CS Child Support

D & E Diagnostic and Evaluative (Services)

DEW Office of Emergency Welfare Services

DHR Department of Human Resources

DMU Data Management Unit

DOL Department of Labor

DPS Department of Pensions and Security

ECP Energy Crisis Program

EPSDT Early and Periodic Screening Diagnosis and

Treatment Program

ETA Employment and Training Administration

EWS Emergency Welfare Services

FCMP Foster Care Maintenance Payments

FSD Food Stamp Division

HHS Health and Human Services

ID Identification

IE Income Eligible

IEVS Income Eligibility Verification System

IFG Individual and Family Grant

JOBS Job Opportunities and Basic Skills Training

Program

MHC Mental Health Counseling (Services)

MR Monthly Reporting

OFA Office of Fraud and Abuse

PAD Public Assistance Division

PARS Public Assistance Reporting System

PR Periodic Reporting

PSD Department of Pensions and Security

RB Retrospective Budgeting

RSDI Retirement Survivors Disability Insurance

SBA Small Business Administration

SPLS State Parent Locator Service

SRS Social and Rehabilitation Services

SS Social Security (Administration)

SSA Social Security Administration

SSI Supplemental Security Income

SUA Standard Utility Allowance

TAD Turnaround Document

TPB Third Party (Insurance) Benefits

TRAN Transitional Day Care Services

WRTI Without Regard To Income

B. Index Organization

Ref. No. Division Program Service

660-2 Economic Assistance Aid to Families with Dependent

Children

Foster Care Maintenance

Payments

Aid to Refugees

Aid to the Blind

Aid to the Permanently and

Totally Disabled

Medicaid Eligibility

Old Age Pension

2.2% Electric Exemption

Program

Office of Work and Training

660-3 Child SupportChild Support

660-4 Food AssistanceFood Stamps

660-5 Social ServicesAdoption Services

Day Care for Adults

Day Care for Children

Emergency Welfare Services

Foster Care for Adults

Foster Care for Children

Homemaker Services for Adults

Homemaker Services for

Children

Individual and Family

Grant Program

Preventive/Supportive

Services (Adult or Family and Children)

Protective Services for Adults

Protective Services for

Children

Residential Care Services for

Delinquent Children and Youth

Residential Care Services for

Individuals with Exceptional

Needs

Ala. Admin. Code r. 660-1-4-B Appendix 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