AB 3 - Review Report on Aid to the Blind (e-form only) AD 2 - Preliminary Examination for Interim Assistance (e-form only) APA 1 - Adult Public Assistance (APA) Program Standards (e-form only) APA 3 - SSA Fax Information Request Form (e-form only) APA 4 - Disability & Vocational Report (e-form only) APA 5 - APA Claims Budget Worksheet (e-form only) APA 11 - Agreement to Sell Property (e-form only) APA 12 - Statement Regarding Principal Place of Residence (e-form only) APA 14 - Protective Payee Agreement (e-form only) ASIR 1 - Agency Staff Interview Report CC# - All Child Care forms can be found on the public website's Child Care Services Forms page. DPA 1 - Public Assistance Programs Brochure (e-form only) DPA 3 - Help Us Stop Fraud Pamphlet (e-form only) DPA 5 - Preparing for your Fair Hearing (e-form only) FA 1 - Fee Agent Interview Report (e-form only) FA 8 - Fee Agent Billing Report (e-form only) FA 9 - Fee Agent Order Form FA 33 - Volunteer Fee Agent Provider Agreement (e-form only) FA 36 - Fee Agent Update Form (e-form only) FA 48 - Fee Agent Monthly Billing Report (e-form only) FA 50 - Fee Agent Application (e-form only) FSP 73 - SNAP Self-Employment Form (e-form only) FSP 74 - SNAP Budget Work Sheet (SPECAT) 10/24 - 09/25 FSP 74 - View archived FSP 74 forms FSP 75 - SNAP Budget Work Sheet (REGULAR) 10/24 - 09/25 FSP 75 - View archived FSP 75 forms FSP 76 – SNAP Program Income Limits 10/24 – 09/25 FSP 79 - SNAP Requirements for Eligibility FSP 80 - How to Use Your SNAP Benefits FSP 81 - SNAP Household Statement Agreement (e-form only) FSP 82 - SNAP Simplified Reporting Flyer FSP 90 - Able Bodied Adult Without Dependents (ABAWD) Pamphlet FSP 91 - Request for ABAWD Work Program Exemption FSP 92 - ABAWD Flier FSP 95 - SNAP Interim Report FSP 101 - Monthly Supplemental Nutrition Assistance Program (SNAP) Report for Residential Facilities FSP 313 - SNAP Makes America Stronger Pamphlet GEN 4 - Transfer of Resources Worksheet (e-form only) GEN 5B - APA Budget Worksheet (e-form only) GEN 5C - ATAP Stepparent/Sponsor Income Worksheet (e-form only) GEN 7 - ATAP Statement of Relationship GEN 8 - Information about the WIC Program (e-form only) GEN 10 - NVRA Voter Preference Form GEN 21 - Stop Payment Affidavit(e-form only) GEN 29 - Record of Native Dividends GEN 30 - Pregnancy Verification GEN 35 - Request for Case File Records GEN 36 - Authorization for Release of Information GEN 37 - Request for Contact Persons and Organizations GEN 38 - Remittance Transmittal (e-form only) GEN 50c - Application for Services GEN 51 - Rights and Responsibilities GEN 53 - Appendix D: Child Support Information GEN 55 - Report of Change GEN 56A - Report of Contact GEN 57 - Additional Household Members GEN 58 - Authorized Representative Permission/Release of Information GEN 60 - General Relief Assistance Cremation-Burial Application GEN 61 - General Relief Assistance Burial Pre-Authorization and Billing Form (e-form only) GEN 72 - Eligibility Review Form GEN 80 - Child Support Cooperation Statement (e-form only) GEN 84 - All About Fair Hearings GEN 85 - Fair Hearing Request GEN 86 - Affidavit of Forgery (e-form only) GEN 87 - Complaint Form GEN 88 - Complaint Results Form GEN 89 - Self Service Portal Reporting GEN 93 - Reporting Changes Pamphlet GEN 94 - Voluntary Application Withdrawal GEN 95 - Report of Claim Determination GEN 101 - Civil Rights Complaint GEN 102 - Review Disposition of Civil Rights Complaint GEN 103 - Withdrawal of Civil Rights Complaint GEN 140a - Referral to Division of Senior Services Home and Community-Based Medicaid Waiver (e-form only) GEN 140b - Referral to Comagine Health (e-form only) GEN 141 - Referral for Disability Determination (e-form only) GEN 142 - Authorization for Reimbursement of Interim Assistance (06-3838) Rev. 08/10 GEN 144 - Division of Public Assistance Confidentiality Statement (e-form only) GEN 150 - HIPAA DHSS Authorization for Release of Protected Health Information (e-form only) GEN 150 IA - HIPAA DHSS Authorization for Release of Protected Health Information (For Interim Assistance applicants only.) (e-form only) GEN 152 - Senior Benefits Application GEN 153 - Direct Deposit Request GEN 155 - Employment Statement GEN 156 - Self Employment Log GEN 157 - Drug Felony Qualifying Condition Verification Form GEN 158 - Felony Qualifying Condition Verification Form GEN 170 - Notification of Suspected Breach of Confidentiality (PDF) GEN 172 - Report of Electronic Theft of Alaska Temporary Assistance Program (ATAP) Benefits (EBT) HAP 1 - Application for Heating Assistance HPE 1 - Application for Presumptive Eligibility for Denali Care/Denali KidCare (PDF) HPE 2 - Hospital Presumptive Eligibility Worksheet (e-form only) (PDF) HPE 3 - Hospital Presumptive Eligibility approval/denial letter (10/16) (PDF) MED 1 - Child's Medical History & Disability Report MED 2 - Authorization for Release of Information (Disability Determination) MED 3 - Declaration/Denial of Asset Transfer (e-form only) MED 4 - Application for Medical Assistance for Adults and Children with Long Term Care Needs MED 6 - Working Disabled Deeming Worksheet (e-form only) MED 7 - Working Disabled Medicaid Worksheet (e-form only) MED 10 - Disability Determination Services Claim Status Inquiry Form MED 12 - Facility Verification Form (e-form only) MED 13 - Denali KidCare Outreach Brochure MED 14 - Medicaid for Individuals Who Need Long Term Care MED 15 - TEFRA Medicaid for Disabled Children at Home If you have trouble accessing the above file with IE, try right-clicking the link and choosing Save Target As... MED 16 - TEFRA Welcome Letter MED 17 - Working Disabled Medicaid Buy-In Brochure (e-form only) MED 19 - ABLE Account Reporting Form (e-form only) MED 20 - Trust Reporting Form MED 21 - Trustee Information (e-form only) MED 22 - Special Needs and Pooled Trusts MED 23 - Qualifying Income Trusts MED 24 - TEFRA Medicaid Nursing Facility Level-Of-Care (e-form only) MED 30 - Medicaid Qualifying Trust Referral (e-form only) MED 31 - Medicaid Qualified Income Trust (e-form only) MED 32 - Medicaid Special Needs/Pooled Trust (e-form only) MED 34 - Denali KidCare Outreach Flyer MED 35 - Denali KidCare Outreach Rack Card MED 36 - TEFRA Initial Application Extension Request Form MED 37 - Certificate of Group Health Plan Coverage Form MED 45 - Request for Newborn Medicaid Identification Number MED 58 - Verbal Authorized Representative Designation Form MED 70 - Asset Verification Authorization MED 72 - Medicaid Simplified Renewal Form NH 8 - Nursing Home Case Resource Assessment Requests (e-form only) NH 9 - Nursing Home Case Resource Assessment (e-form only) PFD 1 - Permanent Fund Dividend Report Form (e-form only) SB 1 - Senior Benefits Program Income Limits TA 1 - Payee Agreement for Minor Parents (e-form only) TA 2 - Family Self-Sufficiency Plan (e-form only) TA 2b - Family Self-Sufficiency Plan Attachment (e-form only) TA 3 - Temporary Assistance Budget Worksheet (e-from only) TA 4 - Temporary Assistance Program Diversion Agreement (e-form only) TA 5 - ATAP Work Services Employment Planning Interview TA 6 - Notification of Rights to Claim Good Cause TA 7 - Alaska Temporary Assistance (ATAP) Eligibility Calculation and Standards (e-form only) TA 8 - Temporary Assistance Payee Agreement (e-form only) TA 10 - Health Status Report Form TA 10a - Health Status Report Form Cover Letter TA 13 - On-the-Job Training Invoice and Performance Review (e-form only) TA 14 - "Your Best Bet" (Penalty Brochure) TA 15 - Family Progress Report - Case Summary and Recommendations (e-form only) TA 16 - ATAP Extension Review Form (e-form only) TA 20 - Applicant Extension Request (e-form only) TA 21 - Employer Application Job Start/On-The-Job Training TA 22 - Job Start Training Agreement (e-form only) TA 23 - Job Start Invoice and Performance Review (e-form only) TA 24 - Job Start Information for Clients (e-form only) TA 25 - Community Work Experience Site Agreement (e-form only) TA 27 - Job Start For Employers Brochure (e-form only) TA 28 - Job Start is For You (e-form only) TA 29 - Job Start/On-the-Job Training Amendment (e-form only) TA 30 - On The Job Training Brochure TA 31 - Community Work Experience Brochure TA 33 - Work Experience Placement Agreement TA 34 - Business Work Experience Site Agreement TA 38 - On-The-Job Training Agreement TA 39 - Community Work Experience and Business Work Experience Timesheet and Evaluation TA 40 - Penalty Resolution Determination TA 41 - Work Services Quarterly Continuous Improvement Plan WS 160 - Work Requirement Handout WS 161 - Work Activities Timesheet (e-form only) WS 162 - ATAP Work Services Performance Invoice WS 163 - ATAP Work Services Supportive Services Invoice WS 164 - ATAP Work Services Grievance Invoice