E-Forms Index By Number

Submitted by Debbie McDonald on September 29, 2017 - 4:43pm
  • 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
  • ATAP 1 - Payee Agreement for Minor Parents (e-form only)
  • CC# - All Child Care forms can be found on the public website's Child Care Services Forms page.
  • CSSD 500b - Release of Information (family violence)
  • CSSD 1603a - Child Support Information
  • DPA 1 - Public Assistance Programs Brochure (e-form only)
  • DPA 5 - Preparing for your Fair Hearing (e-form only)
  • E&T #1- Assessment Information
  • E&T #2 - Participation Plan
  • E&T #3 - Employer Contact Record
  • E&T #4 - Notice To FSP Households Re: WorkRegistration & Employment & Training Requirements
  • FA Poster - Fee Agent Poster (e-form only)
  • FA 1 - Fee Agent Interview Report (e-form only)
  • FA 8 - Fee Agent Billing Report (Excel, Internal Use only)
  • FA 9 - Fee Agent Order Form
  • FA 33 - Volunteer Fee Agent Provider Agreement (e-form only)
  • FA 33A - Volunteer Interpreter 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)
  • FF100 - Families First Feedback and Recommendations (WORD)
  • FF120 - Agreement for Exchange of Information (word)
  • FF130 - Family Support Team Meeting Agenda (word)
  • FSP 73 - Food Stamp Self-Employment Form (e-form only)
  • FSP 74 - Food Stamp Budget Work Sheet (SPECAT) 10/18-09/19 
  • FSP 74 - Food Stamp Budget Work Sheet (SPECAT) 10/17-09/18 
  • FSP 74 - Food Stamp Budget Work Sheet (SPECAT) 10/16-09/17 
  • FSP 74 - Food Stamp Budget Work Sheet (SPECAT) 10/15-09/16 
  • FSP 75 - Food Stamp Budget Work Sheet (REGULAR) 10/18-09/19 
  • FSP 75 - Food Stamp Budget Work Sheet (REGULAR) 10/17-09/18 
  • FSP 75 - Food Stamp Budget Work Sheet (REGULAR) 10/16-09/17 
  • FSP 75 - Food Stamp Budget Work Sheet (REGULAR) 10/15-09/16 
  • FSP 76 - SNAP Program Income Limits (e-form only)
  • FSP 79 - Requirements for SNAP Eligibility (e-form only)
  • FSP 80 - How Do I Use My Food Stamps (e-form only)
  • FSP 81 - Food Stamp Household Statement Agreement (e-form only)
  • FSP 82 - Food Stamp Simplified Reporting Flyer (e-form only)
  • FSP 101 - Monthly Supplemental Nutrition Assistance Program (SNAP) Report for Residential Facilities
  • FSP 313 - SNAP Make 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 6 - Request for Confidential Verification of Vital Event 
  • 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 37 - Request for Contact Persons andOrganizations
  • GEN 38 - Remittance Transmittal (e-form only)
  • GEN 40 - Fraud Complaint Report
  • GEN 46 - Consent of Disclosure
  • GEN 49 - Citizenship Status Declaration (e-form only)
  • GEN 50c - Application for Services
  • GEN 51 - Rights and Responsibilities
  • GEN 55 - Report of Change
  • GEN 56A - Report of Contact
  • GEN 57 - Additional Household Members
  • GEN 58 - Authorized Representative Permission/Release of Information
  • GEN 59 - American Indian or Alaska Native Family Member
  • 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 95 - Report of Claim Determination
  • GEN 97A - Early Fraud Detection Referral
  • GEN 97b1 - Early Fraud Findings Report
  • GEN 97b2 - Action Taken As A Result of EFD Findings
  • GEN 101 - Civil Rights Complaint
  • GEN 102 - Review Disposition of Civil RightsComplaint
  • GEN 103 - Withdrawal of Civil Rights Complaint
  • GEN 140a - Referral to Division of Senior ServicesHome and Community-Based Medicaid Waiver (e-form only)
  • GEN 140b - Referral to Qualis Health and DMHDD (e-form only)
  • GEN 141 - Referral for DisabilityDetermination (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 (e-form only)
  • GEN 154 - EBT Web Admin Request Form (word)
  • GEN 155 - Employment Statement (PDF)
  • GEN 155 - Employment Statement (WORD)
  • GEN 156 - Self Employment Log
  • GEN 165 - Suggestions For EIS Change (DOC)
  • Gen 170 - Notification of Suspected Breach of Confidentiality (PDF)
  • HPE 1 - Application for Presumptive Eligibility for Denali Care/Denali KidCare (07/17) (PDF)
  • HPE 2 - Hospital Presumptive Eligibility Worksheet (04/18) (e-form only) (PDF)
  • HPE 3 - Hospital Presumptive Eligibility approval/denial letter (10/16) (PDF)
  • MED 1 - Child's Medical History & DisabilityReport
  • 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 9 - Medicaid Requirements for U.S. Citizens
  • MED 10 - Disability Determination Services Claim Status Inquiry Form
  • MED 11 - Certification of Medical Status (CAMA)(e-form only)
  • 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 (e-form only)
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  • MED 16 - TEFRA Welcome Letter
  • MED 17 - Working Disabled Medicaid Buy-In Category Pamphlet(e-form only)
  • MED 18 - Children Entering Institutional Treatment (e-form only)
  • MED 20 - Trust Approval Form
  • MED 21 - Trustee Information (e-form only)
  • MED 22 - Special Needs and Pooled Trusts (e-form only)
  • MED 23 - Qualifying Income Trusts (e-form only)
  • MED 24 TEFRA Medicaid Nursing Facility Level-Of-Care (e-form only)
  • MED 26 Declaration of Identity for a Disabled Individual in Institutional Care
  • MED 28 Affidavit to Establish US Citizenship for Medicaid Applicants
  • MED 29 Applicant Declaration to Establish US Citizenship
  • 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 33 Chronic and Acute Medical Assistance (CAMA) Review
  • MED 34 - Denali KidCare Outreach Flyer (e-form only)
  • 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 40 - Health Coverage from Jobs
  • MED 41 - Employer Coverage Tool
  • MED 45 - Request for Newborn Medicaid Identification Number
  • 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 (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 - Temporary Assistance 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
  • TA Notice J090 - Temporary Assistance Case Review Meeting Notice (36/48 month call in letter)
  • TA Notice J091  - Temporary Assistance60th Month Time Limit Meeting Notice (58 month call in letter)
  • TA Notice J092 -Temporary Assistance Request for Continued Extension Letter
  • TA Notice J093 - TemporaryAssistance Continued Extension Call-In (Review) Letter
  • WS 130 - Work Services Travel Report (Excel)
  • 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