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Eforms Numerical List

SFN # Form Title

E-Forms
11 Emergency Assistance Action Plan X
21 Transmitted Between Units X
23 APP For Approval For Relative Child Care Provider X
38 Emergency Assistance Service Application X
52 Spousal Assets X
62 Emergency Assistance Application X
98 Case Management Inter-Agency Referral X
113 Post Secondary Education Information X
132 Dependent Care Payments X
150 60 Month Lifetime Exemption Background Report X
152 Child Support Verification X
162 Request for Hearing X
170 Taxi Voucher

X
187 Medical Expense Worksheet X
200 Asset Assessment X
202 Group Home Drug/Alchohol Treatment Center Monthly Listing X
208 Card Problem Report X
228 Workers With Disabilities Report- Part II X
229 TANF Social Contract X
242 Daily Issuance Report
270 Request for Replacement (SNAP Benefits) X
293 Negative Case Record Review X
319 Monthly EBT Inventory Control Log X
321 Daily Card Issuance Log X
323 JOBS Status Change X
325 EBT Card Stock Transfer X
336 Food Stamp Benefit Conversion Notice
337 Food Stamp Program Claim Review X
338 Child Care Checklist X
339 Monthly Case Management Billing And Reporting X
354 Child Care Assistance Prog Estimate of Day Care Req
362 Food Stamp Computation Sheet X
375 Notice of Assignment of Support Rights (Foster Care) X
376 Drug-Related Felony Review X
378 Change Report Form
384 Quarterly Report of Fraud Control Activities
385 Affidavit For FS Work Registrants X
405 Application For Medicaid, TANF, FS, & CCA X
407 Monthly Report

411

 Aid to the Blind/Remedial Denial Notice X
413 Individual Indian Monies Account X
414 Work Supplementation Agreement
417 Reconciliation with Inventory Recond X
419 Request for Confidential Verification of Birth X
420 Request for Confidential Verfication of Death X
421 Request for Verification of Marriage X
422 Request for Verficiation of Divorce X
423 Kinship Placement X
424 Kinship Care Agreement X
426 Kinship Care Study X
429 Memo Agreement to Establish Protective Payments X
443 Notice of Right to Claim Good Cause X
446 Request to Claim Good Cause X
450 On-Site Review Report X
451 Eligibility Report on Disability/Incapacity X
453 State Review Team Report X
471 Vendor Payment (TANF) Authorize & Req. for Payment X
478 ADD New Record to MMIS Elig File
488 FSP Very Short Case Review X
500 SNAP Targeted Case Review X
501 TANF Re-Assessment X
502 Application for Health Care Coverage X
527 Family Coverage Budget Worksheet X
529 Energy Assistance Program Application X
530 Eligibility and Benefit Worksheet Energy X
537 Payment Rejections
540 Confidential Report of Job Service Unemployment X
560 Assignment of Benefits X
596 EBT Training Referral
598 Child Care Assistance Application X
615 Medicaid Program Provider Agreement

X
616 Child Care Service Report and Bill X
620 Non-Medical Provider X
655 Liheap Case Review X
671 Employment Communication Attendance Roster
679 Employment Communication Orientation Referral X
687 Medicaid Budget Worksheet X
691 Affidavit of Identity for Children X
700 Case Transfer Log X
701 Case Review Short Form X

719

 TANF RFB X
735 Diversion Assistance Screening X
736 Pathways to Work Referral X
737 Diversion Assistance Action Plan X
738 Pathways to Work-Status Change Form x
740 Initial/Strength/Full Assessment X
788 Group Living Arrangement & Drug/Alcohol Treatment Center Report X
805 Requset for anExemption from TANF Lifetime Limit X
817 Health Insurance Cost-Effective Review X
827 Credit Form (Misc. Programs) X
828 Credit Form (Medical Programs) X
841 Child Care Assistance Redetermination Form X
848 Child Care Assistance Provider Request to Pay Parent Directly X
869 Title IV-E Initial Eligibility X
870 Title IV-E Reimbursability X

873

 Income Calculation Worksheet (IV-E) X
880 Contractual Right to Receive Money Payments Valuation Request X
882 Non-Compliance Form
1032 Request From Law Enforcement X
1059 Authorization to Disclose Information X
1076 Growers Statement X
1186 Notice to Annuity Insurer/Medicaid Remainder Beneficiary X
1224 Medical /Child Support Questionnaire X
1444 Mortgage/Collateral Real Estate Mortgage X
1445 Agreement for Real Property Exclusion & Repayment of TANF Grant X
1540 Income Annualizing/Averaging Worksheet X
1681 Near Zero Income Worksheet X
1784 Appeal Background Report X
1906 Anticipated Self-Employment Worksheet X
1940 TANF/Food Stamp Notice of Suspected IPV X
13660 Employer's Report of Injury (Worker's Comp form) X
53401 Energy Assistance - Request for Payment

 

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