The Economic and Employment SERVICES Manual    03-17
FORMS

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Adult Protective Services
Child Care
Employment Preparation
Economic & Employment
Support
Food Assistance
Income Maintenance
Assistance
 

CHILD CARE

Item
Number

Revised
Date

PROGRAM SECTION

File
Format

*

09-05

Child Care Forms Explanations

DOC

PDF

CC-1626A*

01-98

Child Care Provider Denial Notice

DOC

PDF

CC-1630*

07-02

Legally Exempt Release of Information Child Abuse/Neglect Registry Check

DOC

PDF

ECONOMIC & EMPLOYMENT SUPPORT

Item Number

Revised
Date

PROGRAM SECTION

File
Format

ES-524

02-17

Food Assistance Disqualified Recipient Report

DOC

PDF

ES-1100

09-14

Request for Administrative Hearing

 

PDF

ES-1510.1*

10-16

Computation of Food Assistance Benefit Instructions

XLS

 

ES-1512

10-09

Change Report Form

DOC

PDF

ES-1600*

10-02

Civil Rights Complaint

DOC

PDF

ES-1602*

10-04

Child Care Provider Rate Modification

DOC

PDF

ES-1604*

05-05

Daily Attendance Record (Sample Form)

DOC

PDF

ES-1606*

01-07

Request for Supervisory Approval - Child Care Exceeding 215 Per Month

DOC

PDF

ES-1610

10-16

Kansas Early Head Start Child Care Partnerships Referral for Child Care Assistance

 

PDF

ES-1611*

12-05

Request for DCF Child Care Assistance at Flint Hills Job Corps Child Development Center

DOC

PDF

ES-1627*

01-06

Request for Social Service Child Care

DOC

PDF

ES-1627a*

07-08

Request for Enhanced Rate for Special Care

DOC

PDF

ES-1640*

11-16

Statement of Understanding - Employed Income Eligible Child Care Assistance

DOC

PDF

ES-1640a

08-14

Educational Plan Completion Tracking

DOC

PDF

ES-2001

10-06

EES Programs Brochure (Help for Working Families)

 

PDF

ES-2001S

10-06

EES Programs Brochure   (Help for Working Families) (Spanish)

PDF

ES-2002

 

Medicare Savings Plan (MSP)

 

PDF

ES-2007

02-16

Food Assistance Brochure

Insert 2016

PDF

ES-2007

 

Food Assistance Brochure (Spanish) (Under Construction)

Insert 2016

 

ES-3100

07-16

Application for Benefits

 

PDF

ES-3100S

07-16

Application for Benefits (Spanish)

 

PDF

ES-3100AP

10-13

Additional Persons

 

PDF

ES-3100DT

07-14

Acknowledgement of TANF Suspicion-based Drug Testing Policy Spanish

 

PDF

ES-3100APS

12-14

Additional Persons

 

PDF

ES-3100r

07-16

Review Form

 

PDF

ES-3100rS

07-16

Review Form For Families (Spanish)

 

PDF

ES-3100.3

10-04

Certification of Need for Hospital Tuberculosis Treatment

ES-3100.7*

01-13

Application for Medical Coverage - Breast and Cervical Cancer

 

PDF

ES-3100.8

07-12

Application/Redetermination Medicare Savings Plans

 

PDF

ES-3100. 9

07-12

Grandparents as Caregivers Assistance Application

 

PDF

ES-3101*

05-07

Release of Information and Liability

DOC

PDF

ES-3102*

07-16

Important Information About Cooperation

DOC

PDF

ES-3102S*

07-16

Important Information About Cooperation (Spanish)

DOC

PDF

ES-3103*

08-15

Income/Expense Worksheet

XLS

 

ES-3104.1

07-13

TANF Benefit Determination Instructions

XLS

 

ES-3104.5*

04-15

Determination of Need (Medical Assistance)

 

PDF

ES-3104.6*

01-16

Determination Worksheet for PICKLE Eligibles and Other Protected Medical Groups

 

PDF

ES-3105.1*

02-16

Request for Information

DOC

 

ES-3105.1S*

02-16

Request for Information

DOC

PDF

ES-3105.4

07-03

Acknowledgement of Reporting Responsibilities

DOC

PDF

ES-3105.4S

07-03

Acknowledgement of Reporting Responsibilities (Spanish)

DOC

PDF

ES-3106*

10-99

Notice of Action

 

PDF

ES-3107*

10-99

Waiver of Timely Notice of Action

 

PDF

ES-3108*

02-13

Appointment of Authorized Medical Agent for a Minor

DOC

PDF

ES-3109

07-14

TANF Ineligibility Notice

DOC

 

ES-3110

07-14

Negative Drug test

DOC

 

ES-3112

10-16

Referral for an Administrative Disqualification Hearing

DOC

PDF

ES-3113A*

05-00

Eligibility Documentation Log

DOC

PDF

ES-3114

10-14

Food Assistance Interim Report Form

DOC

PDF

ES-3114S

10-14

Food Assistance Interim Report Form

DOC

PDF

ES-3115*

10-09

12 Month Report Form

DOC

PDF

ES-3115S*

10-09

12 Month Report Form (Spanish)

DOC

PDF

ES-3116

10-16

Simplified Reporting for Food Assistance Households

 

PDF

ES-3116S

10-16

Simplified Reporting for Food Assistance Households (Spanish)

 

PDF

ES-3120*

10-99

Initial Interview and/or Referral

DOC

PDF

ES-3141

06-13

Kansas Benefits Card Request for Alternate Payee

 

PDF

ES-3142*

02-17

EBT Benefit Repayment Agreement

DOC

PDF

ES-3143*

01-16

Food Assistance Replacement During Household Disasters

DOC

PDF

ES-3152*

10-04

Medical Assistance Lien Physician Verification

DOC

PDF

ES-3153

05-05

Statement of Continuing Eligibility (Working Healthy)

DOC

PDF

ES-3160

11-14

Notification of Medicaid/HCBS Services Referral/Initial Eligibility/Assessment/ Services Information

DOC

 

ES-3161

11-14

Notification of Medicaid/HCBS/Working Healthy Services

DOC

 

ES-3162*

01-15

Resource Assessment and Allowance Determination Form

 

PDF

ES-3163*

04-15

Income Allowance Determination Form

 

PDF

ES-3165*

04-15

Working Healthy and Premium Information

 

PDF

ES-3166*

01-07

Notification of PACE Information

DOC

PDF

ES-3167

01-08

Annuities and the Kansas Medical Assistance Program Information for Medicaid Applicants and Recipients

DOC

PDF

ES-3167A

05-07

Annuity Information Request

DOC

PDF

ES-3168

07-10

Prepaid Funeral Agreement

 

PDF

ES-3169

01-04

Irrevocable Assignment of Benefits of Life Insurance/Annuity Policy

 

PDF

ES-3170*

10-03

Beneficiary/Patient Spenddown Billed Form

DOC

PDF

ES-3171

10-12

Irrevocable Collateral Assignment of Life Insurance Proceeds

 

PDF

ES-3178

07-09

Authorization Form for the Release of Information

 

PDF

ES-3500

09-16

Low Income Energy Assistance Program Application (LIEAP)

 

PDF

ES-3500S

09-16

Low Income Energy Assistance Program Application (LIEAP)   (Spanish)

 

PDF

ES-3820

10-13

Notice of Eligibility Review

DOC

PDF

ES-3820S*

10-11

Notice of Eligibility Review   (Spanish)

DOC

PDF

ES-3822*

07-06

Notice of Review - Medical Assistance - BCC Program

DOC

PDF

ES-3822A*

07-06

Statement of Continuing Cancer Treatment Medical Assistance - BCC Program

DOC

PDF

ES-3850*

01-08

Record of Identity and Citizenship Documentation

DOC

PDF

ES-3900*

10-06

Tell Us If You Have A Disability

DOC

PDF

ES-3901

10-12

Presumptive Medical Disability Team Referral

DOC

PDF

ES-3903

08-15

KDHE Presumptive Medical Disability Determination Questionnaire

DOC

PDF

ES-3904

08-15

HIPAA Compliant Authorization to Release Information to KDHE

DOC

PDF

ES-3906

07-12

Presumptive Medicaid Disability Determination Notification of Changes and Final Decision Form

DOC

 

ES-3907*

10-06

Disability Review Team Referral

DOC

PDF

ES-3909

08-10

Applicant Instructions for The Presumptive Medical Disability Process

DOC

PDF

ES-4101

01-16

TANF Months in Kansas

DOC

PDF

ES-4102

01-16

TANF Request for Months in other States

DOC

PDF

ES-4103

10-11

School Enrollment Verification

DOC

 

ES-4104*

05-16

Cooperative Work Site Agreement

DOC

PDF

ES-4104.1*

10-06

Work Experience Program Agreement (Addendum)

DOC

PDF

ES-4105*

05-16

Cooperative Community Service Program Agreement

DOC

PDF

ES-4105.1*

10-06

Cooperative Community Service Program Agreement (Addendum)

 

PDF

ES-4106

07-16

Diversion Payment Option Disclaimer

 

PDF

ES-4107

01-14

Expedited Paternity Request

 

PDF

ES-4108

02-17

Collection Site Passport
Collection Sites

DOC

PDF

ES-4109

10-16

Referral for Non-Cooperation with a Fraud Investigation

 

PDF

ES-4304

05-16

TANF Work Hours Verification Checklist

 

XLSX

ES-4305

07-16

TANF Sample Cases Review Guides

 

PDF

ES-4306*

07-13

Employer Contact Record

DOC

PDF

ES-4306F*

05-13

Food Assistance Employer Contact Record
(For Food Assistance Potential Employment Violation Only)

 

PDF

ES-4307*

07-15

Penalty Tracking Sheet

DOC

PDF

ES-4308*

07-16

Hardship Exemption Calculator

DOC

PDF

ES-4309*

12-16

Drs. Statement

DOC

PDF

ES-4310*

10-08

Medical Documentation - Need for Care

DOC

PDF

ES-4312

10-16

ABAWD Eligibility Tracking Form

 

PDF

ES-4313*

01-05

Statement of Understanding for Vehicle Purchase

DOC

PDF

ES-4314*

01-07

Supervisor Checklist for Vehicle Purchase

DOC

PDF

ES-4316*

05-03

Screening/Referral Form

DOC

PDF

ES-4317*

01-11

KHPOP Questionnaire For TANF Customers

DOC

 

ES-4322*

02-07

Community Service/Work Experience Assignment and Site Report

DOC

PDF

ES-4411*

05-16

Claim for Comparable Coverage

DOC

PDF

ES-4412*

10-15

SRCC EES Referral, Report and Turn-Around Document

DOC

 

ES-4413*

04-11

SRCC Monthly Report

 

PDF

ES-4415*

10-12

DCF/DSA Monthly Progress Report

DOC

PDF

ES-4416*

10-12

DCF/DSA Referral Form

DOC

PDF

ES-4417

01-13

DCF/S.A.F.E. Project Referral

 

PDF

ES-4418*

08-15

KeyTrain Referral /Turnaround Form

DOC

 

ES-4419*

10-15

FA E&T Enrollment Form

DOC

 

ES-6010

05-08

Becoming An DCF Child Care Provider Brochure

 

PDF

ES-6075

10-12

Solutions Recovery Care Coordination (SRCC) Brochure Spanish

 

PDF

ES-6077 07-09 Inhome Learning Flyer   PDF
ES-6078 10-10 Partnering For Success Brochure - Work Site Placement   PDF

IS-4308*

01-05

Assessment Referral/Report

DOC

PDF

IS-4315*

05-16

EES & RS Referral/Communication Form

 

PDF

INCOME MAINTENANCE

Item Number

Revised
Date

PROGRAM SECTION

File
Format

IM-3105.5

01-99

Request for Medical Expense Information

 

PDF

IM-3120.6*

01-90

SAVE Verification Report

DOC

PDF

IM-3121

10-94

VA-DCF Information System

DOC

PDF

IM-3140*

05-14

EBT Card Stock Control Log

 

PDF

IM-3140a*

05-14

EBT Card Stock Control Log Attachment

DOC

PDF

ASSISTANCE

Item Number

Revised
Date

PROGRAM SECTION

File
Format

PA-3103.5*

07-85

MAcrSSI Disregard Worksheet (Independent Living and HCBS Only)

 

PDF

PA-3113

07-83

Worksheet Eligibility Unit

DOC

PDF

PA-3120.5*

04-85

Hot Line Referral (Electronic Form)

DOC

PDF

*These forms are to be locally reproduced.