FSEP DCBS Forms - DCBS Training Branch

FSEP Guide DCBS forms for a Family Support Caseworker

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What forms do I use in my case setup? Let’s start with the 116. Let’s start with the 202.

Special Case Forms. 203 Checklist and forms for client. DCBS Intranet Forms Finish

PAFS 116 includes: PAFS 203 PAFS 706 Birth Records Identity Verification Custody, Child Support and Divorce Records DCBS 1 Back to Start

PAFS 202 includes: KIM 101 (Application) FS 8 PAFS 19 PAFS 121 FS 704 PAFS 76 PAFS 700 PAFS 702

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Department for Community Based Services

PAFS-76 (R. 6/08)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

FMTL-403

Information Request Return to:

Case Name: ___________________________ Case Number:__________________________ K-TAP App. FS Recert JT Change MA

Worker Name/Code: ______________________ Address: _______________________________ _______________________________ Phone #: _______________________________ Date: _______________________________

We need to verify information about the person named above. He/She has applied for, or is receiving benefits from state programs and has given your name as a person we can contact who is familiar with his/her situation. Please return to the worker above once completed. Use the back of this form if you need more room for any additional information.

Used to verify Residency, Household composition, Shelter and Utility expenses

Residency What is this person's address (including county) and phone #? _____________________________________________ (Address where this person lives [not mailing address])

__________________________, ________ ___________ (City)

(State)

(Zip)

__________________,

_________________________.

(County)

(Phone #)

Household Composition List everyone who lives at this address.

Are you related to a household member?

Yes

No

Utilities Does he/she pay out-of-pocket money for heating or air conditioning? Yes No Does he/she pay out-of-pocket money for utility expenses other than heating or air conditioning? Are you the manager/landlord?

Yes

Yes

No

No If no, do not complete the landlord section.

For Landlords Only Does this person rent? Yes No How much does he/she pay per week or month? Does this person work in exchange for rent instead of paying? Yes No If yes, how many hours per week? Is the rent paid by, or in part by, anyone other than the person listed above? Yes No If yes, who? HUD Section 8, Other agency, Other person__________________________. How much is paid per week or month? $_______________ Is the check payable only to the recipient, landlord, or both? Are utilities included in the rent? Yes No If no, are utilities billed to the recipient? Yes No Unknown. Does HUD Section 8 or any other agency pay all or part of the utilities? Yes No If yes, how much? $_________ Did this person receive a Home Energy Assistance Program (HEAP) payment for the above listed address? Yes Is utility payment deducted from rent? Yes No If yes, total tenant payment. $___________________

No

Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties provided by state and federal law, including fines, imprisonment or both. I, (Please print your name)

, certify that the information contained in this form is true and correct to the best of my knowledge.

KentuckyUnbridledSpirit.com

An Equal Opportunity Employer M/F/D

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PAFS-19 (R. 11/07)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

FMTL-397

CHILD CARE VERIFICATION Case Name _________________________ Worker _______________________ Date _________________ Case Number ___________________________ Worker Phone Number _____________________________

Child Care Verification Form

____________________________________________ has reported that you provide child care services. Please complete the following. Do not include any amounts charged for kindergarten. Kindergarten expenses are not allowed as dependent care expenses. If childcare is provided for these children after school hours, please include the cost of after school care. Date Began __________________ Day of Week Paid ___________________ Rate Per Child _____________ Paid: Weekly _________ Every Two Weeks __________ Twice a Month ___________ Monthly ___________ Please list payments received for each child during the month of _______________ through ______________ ____________________________ ____________________________ _____________________________ Child's Name Child's Name Child's Name Date Received

Amount

Date Received

Amount

Date Received

Amount

1. 2. 3. 4. 5. 6. 7. 8. Child Care Provider Signature _____________________________ Date ____________ SSN_____________ Day Care Facility Name ____________________________________ Phone Number___________________ Address ___________________________________ City __________________ State _______ ZIP________ “In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.” “To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.” YOU MAY ALSO FILE YOUR COMPLAINT WITH THE CABINET FOR HEALTH AND FAMILY SERVICES, OFFICE OF HUMAN RESOURCE MANAGEMENT, EEO COMPLIANCE BRANCH, 275 EAST MAIN STREET, 5C-D, FRANKFORT, KENTUCKY 40621 OR CALL (502) 564-7770 EXT. 4107. IF YOU HAVE COMPLAINTS ABOUT YOUR CASE, YOU CAN CALL THE OMBUDSMAN'S OFFICE AT 1-800-372-2973. TTY IS AVAILABLE AT 1-800-627-4702. KentuckyUnbridledSpirit.com

An Equal Opportunity Employer M/F/D

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Statement of Disability or Incapacity. Not used for incapacity Medicaid cases.

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Student Income Verification Form

Completed by Financial Aid Office

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Irregular Work Form Used with Odd Job and Seasonal Employment

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PAFS-700 (R. 11 /08)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

Date______________________

Type of Action APP RECERT CHANGE

Case Name ___________________________________________________________ Case Number ______________________

Verification of Employment and Wages

VERIFICATION OF EMPLOYMENT AND WAGES Return to: Worker Name/Code _________________________________________________________ Phone ______________________________

Address ___________________________________________________________________________ Fax ________________________________ Employer_______________________________________________________________________________________________________________ Please provide the following information from your records for ______________________________________________________________________ (Employee Name) (SSN) 1. Employee Name and/or SSN (if different) ____________________________________________________________________________________ 2. Is this person currently employed by you? Yes No 3. Date of most recent hiring _______________________

(Employee Name)

(SSN)

Date first paid ________________________

4. Hourly Pay Rate _________ Overtime Rate________ Anticipated Hours per Week_______ Day of Week Paid___________ Shift Premium _______ 5. Is the employee's share of taxes deducted from gross wages?

Yes

No

6. Is the employee’s hourly Pay Rate scheduled to change? Yes No If yes, the Pay Rate will change to ___________________beginning on ______________________ and will be reflected in the check the employee will receive on _________________________. 7. If the hours listed above have changed, give the normal work hours and date changed: Hrs. ______________ 8. Did the employee voluntarily reduce work hours? 9. Are wages paid weekly, every two weeks,

Date_________________

Yes No If yes, reason ___________________________________________________. twice a month, monthly, other _________?

10. Are wages paid through Title V, Older Americans Act

Yes

No

WIA

Yes

No

OR

Both

Yes

No?

11. List the wages that have been paid during the months of ______________________________ through __________________________________.

Date Received

Hours

Gross Wages

*Tips

**Earned Income Tax Credit (EIC)

Taxes Withheld

Date Received

1.

6.

2.

7.

3.

8.

4.

9.

Hours

Gross Wages

*Tips

**Earned Income Tax Credit (EIC)

Taxes Withheld

5. 10. *Report separately if not included in gross wages. **Report the amount of the EIC payment separately. Do not include EIC in gross wages. 12. Has this employee ever filed a Worker's Compensation Claim?

Yes

No

Date_______________________

13. Is this employee participating in a company retirement plan? Yes No Type of Plan ______________________ Balance of Fund __________ Is there a penalty for early withdrawal? Yes No If yes, what is the amount of the penalty?_____________________

Termination Status:

Fired

Quit

Other

Date __________________

Reason___________________________________________________________________________________________________________________ Date final check received or expected ___________ Gross Amount _______________ Vacation/Sick Pay: Date ___________ Amount ____________ Employer/Business Name____________________________________________________________________________________________________ Please list name, address and telephone number of the company through which payroll is issued, if different. Name______________________________________________________________________________Phone_________________________________ Address____________________________________________________ City_____________________________ State__________ Zip___________ Department for Community Based Services Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties provided by state and federal law, including fines, imprisonment or both. I certify that the information contained in this form is true and correct to the best of my knowledge. Signature _________________________________________________ Title _____________________________________ Date

________________

Print Name____________________________________________________________________________ Phone ______________________________ Address_____________________________________________________City______________________________ State_______ Zip ____________

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PAFS-702 (R. 9/09)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services Department for Community Based Services

PROOF OF NO INCOME Date issued:

Case Name: Case SSN:

To client: Have an individual who knows your situation well and is not a member of your food benefits household; complete this form to verify you have no income. To the individual: Complete this form if you can certify the individual’s income situation. I certify that to the best of my knowledge and belief ______________________________ has had or will have no income from any source during the following month(s): ____________________, ____________________, and ___________________. Warning: Any person who aids another person to obtain assistance (or benefits) fraudulently is subject to penalties provided by state and federal law, including fines, imprisonment or both. I certify that the information contained in this form is true and correct to the best of my knowledge.

Verification of No Income. To be completed by non-member that knows applicants income situation well.

Signature _________________________________________________________________ Print name here ________________________________________________________________________ Date ________________ Phone ___________________________ Address__________________________________________________________________ City ________________________________________________________ State _______ Zip ___________

Return to ______________________________________________, Worker Address ______________________________________________ City __________________________ State ______________ Zip ________ Telephone number ________________________________

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PAFS-203 (R. 1/09)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

CHECKLIST OF FACTUAL INFORMATION PROVIDED Case Name: _______________________________________

Case Number: __________________

Type of Case:

FS

Program Code ___________

Type of Action:

Application

K-TAP

MA

Recertification

Case Change/Member Add

All Program Applications PAFS-4, Important Information for All Who Apply

Checklist for Factual information provided to client.

Civil Rights Pamphlet PAFS-600, Do You Know? (ADA) Food Benefits FS-120, Information Needed to Process a Food Stamp Application FS-360, Facts about Food Stamps FS-500.1, Able-Bodied Adults without Dependents Fact Sheet FSET-101, Food Stamp Employment and Training Program Fact Sheet K-TAP and Medicaid CS-333, Facts about the Child Support Enforcement Program MAP-065, Kentucky Department for Medicaid Services Notice of Privacy Practices PA-3, Facts about the EPDST Services PA-17, Responsibilities for Reporting Changes Medicaid (HCBS, SCL, ICF/MR/DD, LTC) MAP-708, Fact Sheet Medicaid Estate Recovery K-TAP PA-33E, Overview of the PA-33 Process PA-90, K-TAP Lump Sum Income Fact Sheet PA-219, Kentucky Works Assessment Process I have received the forms marked above. My worker has explained the information and answered my questions about the information.

___ (Signature)

_______

__________ (Date)

KentuckyUnbridledSpirit.com

__________ (Worker Init.)

An Equal Opportunity Employer M/F/D

Page 1 of 1

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PAFS-706 (R. 8/08) 921 KAR 3:030 Division of Family Support

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

VOTER REGISTRATION RIGHTS AND DECLINATION ___________________________________ (Applicant or Recipient Name)

___________________________________ (Case Name)

___________________________________ (Applicant or Recipient SSN)

___________________________________ (Case Number)

PART I. RIGHTS 

APPLYING TO REGISTER OR DECLINING TO REGISTER TO VOTE DOES NOT AFFECT THE AMOUNT OF ASSISTANCE THAT YOU MAY BE OR ARE PROVIDED BY THIS AGENCY.



If you register to vote or decline to register to vote, this decision and any information regarding the office to which the application was submitted remains confidential and is used only for voter registration purposes.



If you would like help filling out the voter registration application form, we will help you. seek or accept help is yours. You may complete the application form in private.



If you complete a voter registration application, the voter registration application will be forwarded to your local county clerk. The county clerk will assign you a voting precinct. A confirmation notice with your precinct name and voting location will be mailed to you by the county clerk. If you do not receive this notice within three weeks, please contact your county clerk.



If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register, your right in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint by calling 1-800-246-1399.

Used for Voter Reg. Rights & Declination

The decision whether to

I have read, or have had read to me my rights concerning registering to vote. I understand these rights. I authorize the Department for Community Based Services to release information concerning voter registration to the Kentucky Board of Elections and the County Court Clerks. In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.

Will NOT change the applicants eligibility

YOU MAY ALSO FILE YOUR COMPLAINT WITH THE CABINET FOR HEALTH AND FAMILY SERVICES, OFFICE OF HUMAN RESOURCE MANAGEMENT, EEO COMPLIANCE BRANCH, 275 EAST MAIN STREET, 5C-D, FRANKFORT, KENTUCKY 40621 OR CALL (502) 564-7770 EXT. 4107. IF YOU HAVE OTHER COMPLAINTS ABOUT YOUR CASE, YOU CAN CALL THE OMBUDSMAN’S OFFICE AT 1-800372-2973. TTY IS AVAILABLE AT 1-800-627-4702.

Signed _____________________________________ (Applicant or Recipient)

Date________________________

Cabinet for Health and Family Services

An Equal Opportunity Employer M/F/D Page 1 of 2

Web site: http://chfs.ky.gov/

PART II. DECLINATION

[

]

I do not wish to register to vote at this time. I understand that if I decline to register to vote, my decision is kept confidential and is used only for voter registration purposes.

Signed ________________________________________ (Applicant or Recipient)

Date________________________

Signed ________________________________________ (Worker)

Date________________________

PART III. I have provided the applicant or recipient with a copy of this explanation. Signed _____________________________________ (Worker)

Date________________________

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FS-8 (R. 10/08)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Department for Community Based Services Division of Family Support FOOD STAMP SIMPLIFIED REPORTING REQUIREMENTS HANDOUT

These are reporting rules for your household. The only changes you must tell your worker about are: WHEN YOUR HOUSEHOLD’S MONTHLY GROSS INCOME IS MORE THAN THE AMOUNT LISTED ON THE CHART BELOW FOR YOUR HOUSEHOLD SIZE; OR WHEN A MEMBER OF YOUR HOUSEHOLD WHO IS 18 YEARS THROUGH 49 YEARS OLD, AND SUBJECT TO ABAWD REQUIREMENTS, BEGINS TO WORK LESS THAN 20 HOURS A WEEK. Household 1 2 3 4 5 6 Size Income Limit $1,127 $1,517 $1,907 $2,297 $2,687 $3,077

7

8

Each Additional Member

$3,467

$3,857

+390

Used for Simplified Reporting Requirements, Rights & Responsibilities with all Food Benefit Applications.

If your total gross income in a month’s time is more than the amount listed on the chart for your household size, it must be reported to your worker at the food stamp office. Add all gross earned and unearned income received by your household in a month’s time. Match it up with the amount on the chart. If your household’s gross income is more than the amount listed for your last reported household size, you must report the change within 10 days of the end of the month in which the change occurred. If any working household members, who are age 18 through 49, and subject to ABAWD requirements, have their hours reduced to less than 20 hours per week, you must report to your worker within 10 days. Note: Gross income means the amount of all earned and unearned income before any deductions, such as taxes, are taken out. Other changes may affect your food stamps. You may tell us about these changes that could cause your food stamps to go up or down:  Your household’s income goes up or down.  You move and your rent and/or utilities change.  When someone moves in or out of your household.

Cabinet for Health and Family Services

An Equal Opportunity Employer M/F/D

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Other Case Forms Include: PAFS 126

KIM 77 Back to Start

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

PAFS-126 (R. 2/06) Page 1 of 2

Change Report Form

CHANGE REPORT FORM Date _______________________ (Person Accepting Report)

_____________________________________ (Name of Person Reporting Change)

Used to record reported changes from recipients

(Change Reported: [ ]In Person [ ]Phone

_____________________________________ Type of Case [ ]St. Sup. [ ]MA [ ]FS [ ]K-TAP

(Phone Number of Person Reporting Change)

_____________________________________ (Case Name)

_____________________________________ (Case Number/SSN, if known) Change Referred for Processing to: ___________________________________ (Worker Name)

(Date Referred)

ENTER CHANGE REPORTED IN EACH APPROPRIATE SECTION. I.

ADDRESS CHANGE [ ]Residence Only [ ]Mailing Only [ ]Both New Address: Street City

Apt.# Zip Code

Phone

If mailing address is different from residence, did it change? [ ]Yes [ ]No If yes, Street

Apt.#

City

State

Zip Code

Do the same people live at the new address? [ ]Yes [ ]No If no, also complete section II. Expense Amount Frequency Expense Amount Frequency Rent Mortgage Taxes Insurance Are utilities included in the rent/mortgage? [ ]Yes [ ]No If yes, is the household billed for excess utilities? [ ]Yes (list below) [ ]No Is household billed for heating/cooling expenses? [ ]No [ ]Yes Is household billed for utilities other than heating/cooling expenses: [ ]No [ ]Yes If yes, what are they? _____________________________________________________________________________ Does household receive HEAP? [ ]No [ ]Yes HH eligible for [ ]SUA [ ]BUA [ ]Homeless [ ]Actual Does anyone help with payment of expenses? [ ]No [ ]Yes, who? Does the household receive HUD assistance? [ ]No [ ]Yes, how much? II.

CHANGE IN HOUSEHOLD COMPOSITION Member

In/Out

Date

SSN

DOB

Sex

Race

Relation

If both parents are in home, is either unemployed or incapacitated? [ ]Yes [ ]No Does this person have resources? [ ]Yes [ ]No. If yes, list type and amount. Does this person have income? [ ]Yes [ ]No. If yes, complete section III.

Med. Exp.

Eats W/HH

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KIM-77 KIM-77 (R. 8/08) (R. 8/08) 921 KAR 3:030

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services Division of Family Support

Intent to Apply

Intent to Apply

We want to be able to help you as soon as possible, so please answer the following questions. Do you have a physical or mental condition that requires you to have special accommodations during your application interview, such as needing a sign language interpreter? [ ] Yes [ ] No If Yes, what do you need? ________________________________________________________ We can get a free interpreter for your interview if you have trouble speaking English. Do you need an interpreter during your interview? [ ] Yes [ ] No If yes, what language? ___________________________________________________________

Used for applicants with intent to apply for benefits

Important information for all applicants 

Anyone who wants to receive K-TAP (cash assistance), Food Stamp or Medicaid benefits must give us his or her social security number (SSN) and tell us about his or her citizenship or immigration status. If you do not have a SSN we can help you get one if you are eligible for one. This will not delay your application. Applying for a SSN is voluntary.



SSNs will not be used to report anyone to the Immigration and Naturalization Service (INS).



You do not have to tell us about the SSN, citizenship or immigration status of yourself or anyone else in your home who does not want to receive benefits. Other members of your household can still get benefits if they qualify.



SSNs are used to verify your family’s income and to do computer matches with other agencies such as the Kentucky Department of Employment Services, the Internal Revenue Service and other matching sources.



Anyone applying only for emergency Medicaid does not have to give us his or her SSN or tell us about his or her citizenship or immigration status.



Receiving Medicaid, Kentucky Children’s Health Insurance Program (KCHIP), or Food Stamp benefits will not affect your or your family’s ability to change your immigration status. An exception to this is the use of long-term institutional care, such as a nursing home.



Receiving K-TAP or Supplemental Security Insurance (SSI) could cause problems for immigrants who are trying to change their immigration status, especially if the benefits are your family’s only income. If this applies to you, talk to an agency that helps immigrants with legal problems before you apply.



Refugees and persons granted asylum may receive any benefit, including K-TAP, without hurting their

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Clients receive these forms from the PAFS 203 Checklist : PAFS 120 FS 360 FS 500.1 FSET 101 PAFS 600 Civil Rights Pamphlet Back to Start

Civil Rights Pamphlet Advises all applicants of their civil rights, including their right for a hearing.

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Employment and Training Fact Sheet Information on the Employment Training Program

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Able-Bodied Adults Without Dependents Fact Sheet

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Information Needed to Process a Food Stamp Application

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DCBS-1 (R. 10/05)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

INFORMED CONSENT AND RELEASE OF INFORMATION AND RECORDS Name _________________________________________________________

SSN ______________________________

I understand to help my family and I get the services we need the Department for Community Based Services (DCBS) and other agency staff persons may need to share information and records in order to provide or verify eligibility for these services. By signing this form, I give DCBS staff or staff of another agency, authorized to act on behalf of DCBS, permission to get any information needed to see if I am eligible for any assistance program. I also give permission for DCBS and the following agencies or persons listed below to share information and records with one another about services, benefits or treatment provided to me and my family: Name of Agency or Individual

Name of Agency or Individual

Name of Agency or Individual

My consent includes the following information and records (please put your initials beside each checked item that you consent to): ____ Medical and Physical Health Records (not HIV or AIDS) ____ Behavioral Health and Psychiatric Records (not Drug or Alcohol Abuse Patient Records or Psychotherapy Notes) ____ Psychosocial History ____ Housing Records ____ Psychological Test Results ____ Residential Records ____ Child Care Records ____ Child Support/ Spousal Support Records ____ Student School Records ____ Food Stamp Records ____ Long-term Facility and Alternate Care Records ____ K-TAP Records ____ Statement of Legal Status and Custody ____ Medicaid Records ____ Home Care and Home Health Records ____ Child Protective Services Records ____ Spouse Abuse and Rape Crisis Center Records ____ Adult Protective Services Records ____ Senior Program Provider Records ____ Financial Records ____ Homeless Shelter Records ____ Employment Records ____ Court Records ____ Other____________________________ This consent applies to the following members of my family for whom I have the legal authority to consent: Member Name

SSN

-

Relationship

Member Name

-

SSN

-

Relationship

-

I understand that:  This authorization will be in effect for a period of __________________________ (not to exceed 12 months) from the signature date.  I may revoke this consent at any time in writing unless action has already been taken based on my consent.  DCBS will not condition treatment, payment, enrollment or eligibility for benefits on receipt of this form. Signing this form is voluntary, but failing to sign it, or revoking it before the necessary information is obtained, could prevent an accurate or timely response and could result in denial or loss of benefits.  Information may be disclosed with the other DCBS Divisions to assist in obtaining the requested services.  Information disclosed to DCBS may no longer be protected by the health information privacy provisions of 45 CFR Parts 160 and 164 pursuant to the Health Insurance Portability and Accountability Act (HIPAA).  Information may be redisclosed by DCBS without my consent if authorized by State Law or Federal Laws such as the Privacy Act or 42 CFR Part 2 or to comply with laws regarding mandatory reporting of suspected abuse, neglect or exploitation, or assessment that there is a danger of serious harm to self or others.  I have received a copy of this form. I may also request a copy of the information retained with it. Signature _________________________________________________________________ Date _____________ [ ] Client [ ] Parent [ ] Legal Guardian [ ] Other (specify) _____________________________________________________ Signature ________________________________________________________________ Date _____________ [ ] Client [ ] Parent [ ] Spouse [ ] Legal Guardian [ ] Other (specify) ___________________________________________ Witness Signature _________________________________________________________

Date _____________

Consent and Release of Client Information and Records.

Used when additional information needs to be obtained from a third party.

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PAFS-600 (1/09)

COMMONWEALTH OF KENTUCKY Cabinet for Health and Family Services Department for Community Based Services

DO YOU KNOW? Do you have a physical or mental condition that makes it hard for you to: Apply for K-TAP, Medicaid, Food Benefits or other benefits? Keep appointments with us? Do a task or activity we ask you to?

PAFS 600 Fact sheet for Americans with Disabilities Act (ADA)

If you do, we can help you. We can also help you if you care for a family member and that care makes it hard for you to get benefits. This flyer tells you why and how we can help. Americans with Disabilities Act (ADA) The law: You have the right under the Americans with Disabilities Act (ADA) to get help applying for and keeping benefits. You can get help with any activity needed to use our programs. Who it protects: You have rights under the ADA if any kind of health problem makes it hard for you to do something basic and important, like: •care for yourself •walk, stand, or sit •see, hear, or talk •breathe •learn •remember things •do tasks with your hands •work The problem can be physical, like diabetes, asthma, or migraine headaches. Or it can be mental or emotional, like depression, anxiety, ADD or ADHD. It can also be a learning disability. You do not have to get disability benefits to get this help.

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Facts About Food Stamp Benefits Information Fact Sheet

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DCBS FORMS Intranet; forms for family support caseworkers.

Next Screen

Family Support Forms: Access General Forms Workbook, or scroll page to access Table of Contents for Family Support forms.

Comprehensive Table of Contents: Section I Food Stamp Forms Section II Public Assistance/Food Stamp Forms Section III Public Assistance Forms Section IIIA KWP Forms Section IV DCBS Forms Section V Claims/Fraud Forms Section VI Miscellaneous Forms Section VII Publications Section VIII KAMES Forms Section IX Report Series Forms

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Don’t forget: Some local offices use additional forms for case setup. Check with your supervisor regarding your office procedures. You are now ready to continue with assignments under Part I on Blackboard.

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