The Economic and Employment Services Manual 02-26 MISCELLANEOUS FORMS

Miscellaneous Forms are created by agencies/divisions outside of EES and are placed in the KEESM for the convenience of staff.

Administrative Disqualification Hearings	Administrative Hearings	Fraud	HIPAA	IRS	Repatriation Program

ADMINISTRATIVE DISQUALIFICATION HEARINGS
	Revised Date	Title	File Format
	11-03	Action Taken on Your Administrative Disqualification Hearing (Not Guilty)*	DOC	PDF
	11-04	Action Taken on Administrative Disqualification Hearing (Guilty)*	DOC	PDF
	11-04	Action Taken on Administrative Disqualification Hearing (Waiver)*	DOC	PDF
		Advance Notice of Administrative Disqualification Hearing*		PDF
	01-03	Waiver of Right to Administrative Disqualification Hearing		PDF
ADMINISTRATIVE HEARINGS
	Revised Date	Title	File Format
		Administrative Hearing Brochure	DOC	PDF
	01-03	Notice of Withdrawal of Appeal		PDF
		Decision Compliance Report* (Staff will get this form if the fair hearing is reversed and staff have to take action to correct the case.)	DOC	PDF
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FRAUD
Item Number	Revised Date	Title	File Format
FRS-1	01-09	Referal for Alleged Client Fraud		XLS

HIPAA
Item Number	Revised Date	Title	File Format
ADM-2000	04-03	Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice)		PDF
ADM-2000S	02-05	Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice) (Spanish)		PDF
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INTERNAL REVENUE SERVICE
Item Number	Revised Date	Title	File Format
W-9	03-24	Request for Taxpayer Identification Number and Certification		PDF
		Title	File Format

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*EES staff information only.