Miscellaneous Forms are created by agencies/divisions outside of EES and are placed in the KEESM for the convenience of staff.
11-03
Action Taken on Your Administrative Disqualification Hearing (Not Guilty)*
DOC
PDF
11-04
Action Taken on Administrative Disqualification Hearing (Guilty)*
Action Taken on Administrative Disqualification Hearing (Waiver)*
Advance Notice of Administrative Disqualification Hearing*
01-03
Waiver of Right to Administrative Disqualification Hearing
Administrative Hearing Brochure
Notice of Withdrawal of Appeal
Decision Compliance Report* (Staff will get this form if the fair hearing is reversed and staff have to take action to correct the case.)
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FRS-1
01-09
Referal for Alleged Client Fraud
XLS
ADM-2000
04-03
Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice)
ADM-2000S
02-05
Notice of Use of Private Health Information (HIPPA Notice of Privacy Practice) (Spanish)
Emergency and Group Processing Form
Emergency and Group Repatriation Financial Form
Federal Interagency Emergency Repatriation Workgroup (FIER) Contact Form
Loan Waiver Request Form
Non-Emergency Monthly Financial Statement Form
Privacy and Repayment Agreement Form
Refusal of Temporary Assistance Form
State Request for Federal Support Form
Temporary Assistance Extension Request Form
*EES staff information only.