The Economic and Employment SERVICES Manual    10-17
FORMS

These documents are intended primarily for staff use and are linked here for reference purposes only. When selecting a document other than PDF, you may need to select "Save", and save the document to your computer. Then you can open the document with the appropriate application (Word, Excel).

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

ECONOMIC & EMPLOYMENT SUPPORT

Item Number

Revised
Date

PROGRAM SECTION

File
Format

ES-524

02-17

Food Assistance Disqualified Recipient Report

DOC

PDF

ES-1510.1*

10-17

Computation of Food Assistance Benefit Instructions

XLS

 

ES-1512

05-17

Change Report Form

DOC

PDF

ES-1600*

10-02

Civil Rights Complaint

DOC

PDF

ES-1601

08-17

Affidavit of Identity

 

 

ES-1603

08-17

Address Change-Voter Registration Information

 

 

ES-1610

10-17

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-1640a

08-14

Educational Plan Completion Tracking

DOC

PDF

ES-2007

10-17

Food Assistance Brochure

Insert 2017

PDF

ES-2007S

10-17

Food Assistance Brochure (Spanish)

Insert 2017

PDF

ES-3100

10-17

Application for Benefits

 

PDF

ES-3100S

07-16

Application for Benefits (Spanish)

 

PDF

ES-3100AP

10-13

Additional Persons

 

PDF

ES-3100APS

12-14

Additional Persons (Spanish)

 

PDF

ES-3100DT

07-14

Acknowledgement of TANF Suspicion-based Drug Testing Policy (Spanish)

 

PDF

ES-3100r

07-16

Review Form

 

PDF

ES-3100rS

07-16

Review Form For Families (Spanish)

 

PDF

ES-3100. 9

07-17

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

07-17

TANF Benefit Determination Instructions

XLS

 

ES-3105.1

02-16

Request for Information

DOC

 

ES-3105.1S

02-16

Request for Information (Spanish)

DOC

 

ES-3106*

10-99

Notice of Action

 

PDF

ES-3107*

10-99

Waiver of Timely Notice of Action

 

PDF

ES-3112

10-16

Referral for an Administrative Disqualification Hearing

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-3117

08-17

Purchase and Prepare Statement

DOC

 

ES-3141

10-14

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-3144

08-17

Food Assistance Adjustment Notice

 

 

ES-3145

08-17

Kansas Benifits Card-Important notice (FA)

 

 

ES-3146

08-17

Kansas Benifits Card-Important notice (CA)

 

 

ES-3147

08-17

Restricted Use of TANF Benefits

 

 

ES-3148

08-17

Claim Balance Change-Overpayment Paid with Kansas Benefits Card

 

 

ES-3900*

10-06

Tell Us If You Have A Disability

DOC

PDF

ES-4101

01-17

TANF Months in Kansas

DOC

PDF

ES-4102

01-17

TANF Request for Months in other States

DOC

PDF

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-4303

08-17

Sample Month Participant

DOC

 

ES-4304

07-17

TANF Work Hours Verification Checklist

 

XLSX

ES-4305

07-17

TANF Sample Cases Review Guide

 

PDF

ES-4308*

07-17

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-4313*

07-17

Statement of Understanding for Vehicle Purchase

DOC

PDF

ES-4314*

01-07

Supervisor Checklist for Vehicle Purchase

DOC

PDF

ES-4316*

07-17

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-6078 10-10 Partnering For Success Brochure - Work Site Placement   PDF

IS-4308*

07-17

Assessment Referral/Report

DOC

PDF

IS-4315*

07-17

EES & RS Referral/Communication Form

 

PDF

INCOME MAINTENANCE

Item Number

Revised
Date

PROGRAM SECTION

File
Format

IM-3120.6*

01-90

SAVE Verification Report

DOC

PDF

IM-3121

10-94

VA-DCF Information System

DOC

PDF

ASSISTANCE

Item Number

Revised
Date

PROGRAM SECTION

File
Format

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.