The Economic and Employment SERVICES Manual    10-20
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).

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*

10-20

Computation of Food Assistance Benefit Instructions

XLS

 

ES-1512

05-17

Change Report Form

DOC

PDF

ES-1512FC

06-20

Changes for Foster Care Child Care Benefits (Spanish)

 

PDF

ES-1600*

10-02

Civil Rights Complaint

DOC

PDF

ES-1601

08-17

Affidavit of Identity

DOC

 

ES-1603

08-17

Address Change-Voter Registration Information

DOC

 

ES-1610

10-20

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*

05-18

Request for Social Service Child Care

DOC

PDF

ES-1627b*

07-19

Referral for Child Care for Children in Safe Families or Relative or Non-Relative Kinship Foster Care

DOC

 

ES-1640

07-19

Statement of Understanding

 

PDF

ES-1640a

08-14

Educational Plan Completion Tracking

DOC

PDF

ES-2007

09-19

Food Assistance Brochure

Insert 2020

PDF

ES-2007S

09-19

Food Assistance Brochure (Spanish)

Insert 2020

PDF

ES-3100

05-20

Application for Benefits

 

PDF

ES-3100S

05-20

Application for Benefits (Spanish)

 

PDF

ES-3100FC

07-20

Application for Foster Care Child Care Benefits (Spanish)

 

PDF

ES-3100APS

12-14

Additional Persons (Spanish)

 

PDF

ES-3100DT

06-20

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

DOC

PDF

ES-3100r

04-20

Review Form

 

PDF

ES-3100rS

05-19

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

05-19

Food Assistance Optional Release of Information

 

PDF

ES-3103S

05-19

Food Assistance Optional Release of Information (Spanish)

 

PDF

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*

08-17

Waiver of Timely Notice of Action

 

PDF

ES-3108*

05-18

Request for Employment Information

DOC

 

ES-3112

10-16

Referral for an Administrative Disqualification Hearing

DOC

PDF

         

ES-3114

04-20

Food Assistance Interim Report Form

 

PDF

ES-3114S

10-14

Food Assistance Interim Report Form

DOC

PDF

ES-3115*

04-20

12 Month Report Form

 

PDF

ES-3115S*

10-09

12 Month Report Form (Spanish)

DOC

PDF

ES-3117

08-17

Purchase and Prepare Statement

DOC

 

ES-3120.5*

05-18

Agency Fraud Referral

DOC

 

ES-3141

10-14

Kansas Benefits Card Request for Alternate Payee

 

PDF

ES-3142*

01-19

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

DOC

 

ES-3145

08-17

Kansas Benefits Card-Important notice (FA)

DOC

 

ES-3146

08-17

Kansas Benefits Card-Important notice (CA)

DOC

 

ES-3147

08-17

Restricted Use of TANF Benefits

DOC

 

ES-3200

01-19

Kansas Voter Registration Application

 

PDF

ES-3200S

01-19

Kansas Voter Registration Application (Spanish)

 

PDF

ES-3148

08-17

Claim Balance Change-Overpayment Paid with Kansas Benefits Card

DOC

 

ES-3500

10-20

Low Income Energy Assistance Program Application (LIEAP)

 

PDF

ES-3500A

10-19

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

 

PDF

ES-3500S

10-20

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

 

PDF

ES-3501

10-18

Subsidized Housing Worksheet (Deep Subsidy)

XLS

 

ES-3900*

10-06

Tell Us If You Have A Disability

DOC

PDF

ES-4101

09-18

TANF Months in Kansas

DOC

 

ES-4102

09-18

TANF Request for Months in other States

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-4108

08-19

Collection Site Passport
Collection Sites

 

PDF

ES-4302

02-18

Employer Letter for TANF Samples

DOC

 

ES-4303

08-17

Sample Month Participant

DOC

 

ES-4304

07-19

TANF Work Hours Verification Checklist

 

XLSM

ES-4305

10-20

TANF Sample Cases Review Guide

 

PDF

ES-4308*

07-17

Hardship Exemption Calculator

DOC

PDF

ES-4309*

12-16

Drs. Statement

DOC

PDF

ES-4310A*

03-19

Need For Care Adult Medical Documentation

DOC

 

ES-4310C*

03-19

Need For Care Child Medical Documentation

DOC

 

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*

01-12

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*

10-18

SRCC Monthly Report

DOC

PDF

ES-4415*

01-20

DCF/DSA Monthly Progress Report

DOC

 

ES-4416*

01-20

DCF/DSA Referral Form

DOC

 

ES-4417

01-13

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

 

PDF

ES-4418*

08-15

KeyTrain Referral /Turnaround Form

DOC

 

ES-6010

05-08

Becoming A 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

*These forms are to be locally reproduced.