Kansas Department of Social and Rehabilitation Services
Don , Secretary

Integrated Service Delivery - Candy Shively, Deputy Secretary (785) 296-3271

Economic and Employment Support - Bobbi Mariani, Director (785) 296-3349
....Enriching lives today and tomorrow



Regional Directors, ISD Directors, EES Program Administers, Community Capacity Directors, EES Field Staff, and EES Central Office Staff


December 5, 2007


Bobbi Mariani


Implementation of New Application Forms

I am pleased to announce that the new application forms are at the State Printer and are being printed for immediate distribution. The revised forms should appear in local offices in mid December. See attached copies of the new forms. Also refer to the Summary of Change for KEESM Revision 30 effective January 1, 2007, item I, A, 1.

The following implementation information is being provided about the new forms:

  • The current ES-3100, Application for Cash, Health Care, Child Care and Food Stamp Benefits is being replaced with two forms, the ES-3100, Application for Benefits for Families and the ES-3100.1, Application for Benefits for the Elderly and Persons with Disabilities. Applicants can apply for food assistance, cash assistance (TANF, Refugee), child care assistance and medical assistance (for families and pregnant women) on the ES-3100. Applicants completing the new ES-3100.1 can apply for medical assistance (elderly and disabled), food assistance and cash assistance (General Assistance).


Note: The old ES-3100 and Addendum can continue to be used until supplies are exhausted.

  • The old ES-3100.1, Addendum to the Application is obsolete (unless the old ES-3100 is used) with the new applications as the information gathered on the Addendum is now gathered on the revised applications.
  • The new ES-3100.1 replaces the ES-3100.4, Application/Redetermination for Health Care Coverage and Food Stamps for Elderly and Persons with Disabilities (Including Medicare Savings Programs), and the ES-3100.4a, Instructions for Completing the ES-3100.4. Also Section H of the ES-3100.1 replaces the ES-3900, Tell Us If You Have a Disability form.


Note: The ES-3100.4 and 3100.4a can continue to be used until supplies are exhausted. If the old forms are used, the ES-3900 is still required when appropriate.

  • With the implementation of the new application forms, the ES-3100.6, Welcome to the Kansas Food Assistance Program is also being obsoleted. Current supplies of this form may be used until supplies are exhausted.
  • As you can see by the attached copies, the applications are in color for the first time, with icons to guide applicants through the form. The front cover page of the forms contains self explanatory instructions and page one of the application is on the back of the cover page.


Due to USDA requirements, the first page of the application contains space for the applicant to provide their name, address and signature to file the application and establish the filing date. Applications for assistance must be accepted if this is the only information completed; however, the rest of the application must be completed before eligibility can be determined.

  • Also on page one of the ES-3100 a box is included in Section B for applicants to check if they have been a victim of domestic violence (DV) or sexual assault (SA) and they want special considerations and services, including a confidential interview. If the box is checked, staff are to refer the applicant to the local DV or SA subcontracting agency to receive DV/SA services. If TAF is approved, staff shall send a referral to the OARS Advocate to complete an assessment to determine if the TAF recipient is eligible for OARS services. Otherwise, all non-TAF customers will receive DV or SA services at the local subcontracting DV/SA agency.
  • The last page of both applications is a  tear off  information page that the applicant is to remove and keep. If the applicant does not remove this last page when they submit the application, staff should remove it and provide it to the applicant, either in person or by mailing it to the applicant.


In addition, the back of the tear off page has an Interview Section which can be used to schedule the interview for applicants filing the application in the office and who are not interviewed the same day. A  box is provided for an address stamp where the interview will be conducted, along with check boxes that are self explanatory.

  • For distribution to Access Points, the cover of both applications has a box for local offices to include an address stamp where the application should be returned. Both applications should be stocked at Access Points.
  • Other services are also noted on the cover page – Child Support Enforcement and Vocational Rehabilitation. If these boxes are marked by the applicant, referrals to these programs are required. Local procedures are to be developed for these referrals.
  • On page 3 of the applications, a question is still included regarding drug-related felony convictions occurring after August 22, 1996, even though answering yes no longer results in ineligibility. It was felt this information was important for work program purposes.
  • Both applications are being translated into the following languages: Spanish, Laos, Hmong, Vietnamese, Somali, Low German, Arabic, Farsi, Russian and Swahili. Only the Spanish versions will be printed by the State Printer and available from the warehouse. The applications in the other languages will be available to down load for local printing as needed from the SRS and EES websites. More information will be provided on this process when the applications have been completely translated.


I would like to especially thank the following field staff who graciously field tested the revised applications: Max Pierce, Irene Lowry, Georgia Masterson and the staff of the El Dorado and Chanute SRS offices. The testing process resulted in numerous improvements to the forms. Also providing key input to the ES-3100.1 was the Long Term Care Workgroup.  I would also like to thank Leslie Fisher in Central Office for her extra efforts in getting this job completed.

If you have any questions about the new forms, please contact Pam Jacob.

Cc: Don Jordan
      Candy Shively

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