Form ID |
Form Name |
Form Description |
|---|---|---|
A827 |
TANF Fraud Disqualification, Non-Recipient | TANF Fraud Disqualification, Non-Recipient This is a form sent to the consumer when a person is disqualified from TANF. The form also provides the reason for the disqualification. |
A828 |
TANF/CC Fraud Disqualification - Perm | Notice sent to consumer advising there is a TANF/CC fraud disqualification and the effective date. |
A831 |
TANF Repay Agreement-Fraud Recipient | This form is sent to a consumer to notify them of an overpayment amount and the reason the over-payment occurred. The form provides a repayment agreement that must be signed and returned to the agency. |
A832 |
TANF Repayment Agreement - Agency/Consumer Recipient | This form is sent to the consumer to notify them that an overpayment has occurred and provides the reason for the overpayment. The form has a repayment agreement that must be signed and returned to the agency. |
A836 |
Repayment Agreement-Agency/Consumer Non-Recipient, CCU | This form is sent to the person in the household who is responsible for the overpayment to inform them of the total amount of overpayment and the month(s) the overpayment occurred. It contains a repayment agreement that must be signed and returned to the CCU. |
A837 |
TANF Repayment Agreement: Fraud Non-Recipient CCU | This form is sent to the person in the household who is responsible for the overpayment to inform them of the total amount of overpayment and the month(s) the overpayment occurred. It contains a repayment agreement that must be signed and returned to the CCU. |
B-4 |
Motion to Dismiss | This is a legal form sent to the Office of Administrative Hearings requesting dismissal of the Appellant's request for a fair hearing. The agency worker also sends a copy of the Motion to Dismiss form to the appellant. |
B-5 |
Fair Hearing Summary | This is the template used to provide a summary of fair hearing information to the Office of Administrative Hearings in the Ks. Dept. of Administration. |
C-26 |
Referral for Child Care Provider Enrollment Application | This form is the Provider enrollment application. It is completed by DCF staff and sent to the Provider Enrollment Mailbox |
C103 |
Enrollment Fee Request | This form is sent to the consumer to give to the provider when the provider requests an enrollment fee. |
C104 |
Enrollment Fee Denial | Notification to consumer their request for help with enrollment fees for child care is denied. |
C109 |
Provider Information Request | This form is sent to the consumer requesting information regarding which provider the parent is using. If no contact with the agency the child care case will be closed. |
C110 |
Child Care Benefits Balance | This form is sent to the consumer to request information regarding the need for continued child care services. If no response the case will be closed. |
C112 |
Claim Balance Change - Paid with EBT Benefits | This form is sent to the consumer to provide information regarding a change in claim amount due to a payment made with EBT benefits. Send the V808 with Standard Copy and Paste Text. |
C202 |
CC Subsidy Eligibility Notice | Notice informing consumer they are eligible for Child Care subsidy. |
C504 |
Termination - Payment to Different Provider | This form notifies the consumer that the child care plan for child on the case is ending due to payment being made to a Provider who is not listed on the child care plan. |
C505 |
Termination - Non-Payment to Provider | Notice sent to consumer that child care plan(s) are ending because child care benefits have not been used for payment of child care for a two-month period. |
C506 |
Termination - Child Care Provider Agreement Ending | Notice to consumer advising child care plans to provider are ending. |
C507 |
Termination of Relative or In-home Provider | Notice to consumer advising child care plans to provider are ending. |
C811 |
Child Care Family Plan | This is sent to the consumer giving a detailed description of child care plan benefits per child per provider per month for the upcoming year. |
C911 |
Child Care Benefit Repayment Agreement | Demand letter to consumer after an overpayment has been determined. |
C912 |
CC Overpayment Claim Change | Notification to consumer their child care overpayment claim has been changed. |
C915 |
Child Care Overpayment Repayment Plan | Follow up letter to consumer after an overpayment has been determined and the C911 demand letter was sent previously. |
CCU Bill 001 |
Billing Statement | Form to be sent when there are no active programs and there are active overpayment recovery accounts. |
ES-1100 |
Request for Administrative Hearing | This form is completed by an applicant, consumer or other interested party to request a fair hearing to review an action taken by DCF. |
ES-1607 |
Provider Denial Notification | This form is sent to a provider applicant to inform them that their request to become a DCF provider has been denied and provides the reason for the denial. |
ES-1627a |
Request for Enhanced Child Care Rate | Reason for Request: this benefit is available for a special needs child who has a need for specialized support services. It is available for a child who has a temporary or permanent disability and requires special care services by their caretaker. |
ES-1640 |
Child Care Statement of Understanding | This form is given or sent to a consumer explaining eligibility requirements for benefits while attending school or training classes. |
ES-3100R |
DCF Review Form | Cover letter and review combined form sent to consumers advising them they in order to have benefits continue, this form must be completed and returned to the DCF office. |
ES-3102 |
Important Information About Cooperation with Work Program | This form is discussed with the consumer in the initial face to face interview for determining eligibility or when a person is assigned to a work program. In some situations, the form will be mailed to the consumer. Send from KEESM. |
ES-3105.1 |
Request for Information | This form is sent to the consumer to request information needed to determine initial eligibility or continued eligibility for a specific DCF program(s). |
ES-3114 |
Food Assistance Interim Report Form | This form is sent or given to the consumer to complete for an interim report of information. |
ES-3115 |
Food Assistance 12 Month Report Form | This form is sent or given to the consumer to complete for the 12 month report of information. |
ES-3116 |
DCF Reminder Form | This form is sent to a consumer to remind them that their Interim Report form was due. |
ES-3121 |
VA Information Request | Form sent to VA Administration for income information for consumers and dependents. |
ES-3501 |
LIEAP - Request for Information | This form to send to a LIEAP applicant to request information needed to process the LIEAP application. |
ES-4103 |
School Verification Request | This form is sent to the consumer to sign and take to the school to verify school enrollment for children who receive cash assistance. |
ES-4306 |
Employer Contact Record | Form sent to consumer for recording job search contacts which are then returned to DCF. |
ES-4306F |
Food Assistance Employer Contact Record | Form sent to consumer to record job contacts for food assistance. |
ES-4309 |
Medical Report | DO NOT USE |
ES-4318 |
Work Program Payment Authorization | Document sent to consumer - authorizes the purchases necessary for employment preparation. |
F602 |
Benefits Paid Pending Hearing Decision | Notification to consumer their benefits will continue at the previous level pending a fair hearing decision. |
F827 |
FA Fraud Disqualification - Nonparticipating Individual | This form is sent to the consumer to inform them that someone on the case has been disqualified for fraud. |
F828 |
FA Fraud Disqualification - Permanent | This form is sent to inform the consumer of the name of the person who has been disqualified permanently from the Food Assistance program. |
F830 |
FA Fraud Disqualification - Participating Individual | Notice to consumer benefits are being reduced due to individuals’ fraud disqualification. |
F831 |
FA Repayment Agreement-Fraud-Participating Household | This form is sent to request that the consumer complete a repayment agreement for recovery of a fraudulent food assistance overpayment. |
F832 |
FA Repay Agreement-Agency-Consumer Error Participating HH | This is a form sent to the consumer to notify the household that an overpayment has occurred due to agency or consumer error and to request repayment. |
F835 |
FA Repayment Agreement Reminder | Notice sent to household reminding them of their previous agreement to repay a food assistance overpayment by making monthly payments. |
F836 |
FA Repay Agreement Agency-Client Non-Recipient CCU | Notice of repayment sent to adults who have received an overpayment of food assistance benefits due to client or agency error. |
F837 |
FA Repayment Agreement Fraud Non-Recipient CCU | Notice of repayment sent to adults who have received an overpayment of food assistance benefits due to fraud. |
F847 |
Food Assistance Interim Report | Incomplete NoticeInformation request sent to households receiving food assistance to obtain information needed to complete interim reporting requirement. |
FIN-001 |
Receipt | Form generated from the Receipt Detail Page when client makes a payment on an active overpayment. |
FIN-002 |
Balance Letter | Form generated from the Transaction Detail page advising the client a payment has been received on an active overpayment and giving a current balance owed amount. |
L-1 |
LIEAP Landlord Information Request | This form is sent to the Landlord of the LIEAP Applicant to complete. The completed form will provide verification regarding utilities at the residence listed on the application. |
L-3 |
LIEAP Review of Denial | Letter sent to consumer advising the status of review of agency action. |
L-5 |
LIEAP Notice of Overpayment | Notice to consumer advising of a LIEAP benefit reduction due to overpayment. |
L-6 |
LIEAP Outreach Form | Letter sent to consumer's eligible to receive LIEAP during the Prior LIEAP season, informing them to apply for LIEAP benefits via the SSP using their case number (provided in the letter) for the upcoming season. |
PPS 6135 |
Adoption Assistance Review | Form sent to parents of primary applicant to complete and return to determine continued eligibility. |
PPS 6165 |
Permanent Custodianship Annual Report | Form sent to Custodial parents of primary applicant to complete and return to determine continued eligibility. |
P101 |
Child Care Provider General | NoticeGeneral Correspondence not reason specific to Child Care Providers. |
P104 |
Rate Change Completed - CCC | This form is sent to the child care center provider to confirm that the request for a change in rate modification has been completed and the month that the change becomes effective. |
P105 |
Rate Change Completed - Lic | This form is sent to a licensed child care provider to confirm that the request for a change in rate modification has been completed and the month that the change becomes effective. |
P106 |
Child Care Provider Notification | This form is sent to a Child Care Provider to inform them that their DCF Child Care Agreement will be continued. It also provides general instructions for providers. |
P107 |
Child Care Provider Approval Notice | Notification to providers they have been approved to receive state payment for child care. |
P108 |
Child Care Provider Request for Information | Notification to potential providers - additional information is needed to determine if agreement will be made for state payment for child care. |
P109 |
Child Care Provider review | Notification for relative or in-home child care providers to complete a review to determine if they can remain providers. |
P201 |
Child Care Provider Denial/Termination Notice | To notify CC Providers their agreement with the state is being denied or terminated. |
P202 |
Child Care Provider Eligibility Notice | Notification to provider they are eligible to receive state payment for child care. |
P501 |
Provider Notice - Plan Ended | Notification to provider that child care plans for specified children has ended. |
P911 |
Provider Overpayment - Repayment Agreement | Notification to Child care provider they have been over paid by the state for services and repayment is required. |
P912 |
Provider Overpayment Change - Reduction | Notification to Child care provider that a previously determined overpayment has been reduced. |
P913 |
Provider Overpayment Claim Deletion | Notification to child care provider that a previously determined overpayment has been deleted. |
P914 |
Provider Overpayment Claim Addition | Notification to child care provider a previously determined overpayment has been added to. |
P915 |
Provider Overpayment Repayment Plan | Notification to a child care provider - follow up to previous overpayment letter that this overpayment will be collected and how that will happen. |
P917 |
Provider Failed Audit Notice | Notification to child care provider they failed a state business audit and reasons for failure. |
P918 |
Child Care Provider Audit | Notification to CC Provider they are being audited. |
QA-1 |
QA Letter to Household | This form is sent to the consumer to let them know that their FA case has been randomly selected for review by the Quality Assurance Unit. |
TOP 60 |
TOP 60 Day Notice | This form is part of Batch SWRun81C - sent to the consumer to notify them that they have not repaid an existing FA overpayment(s). If not paid within 60 days the claim will be sent to the Treasury Offset Program. |
V000 |
Verification Request List | This is a generic form sent to the consumer to request specific verification(s) needed to determine or maintain eligibility. The form is to be returned to the agency along with the requested information. |
V003 |
Request for Employment Information | This form is sent to the consumer to request employment information. The majority of the form is completed by the employer. |
V004 |
Landlord/ Residency Verification Request | This from is sent to the consumer to request landlord and residency verification. The consumer sends/takes the form to the landlord, who completes the form. |
V006 |
Unreported Income Verification Request | This form is sent to the consumer to request verification of unreported income. |
V007 |
Medical Expense Verification Request | This form is sent to the consumer to request verification of medical expenses for the Food Assistance Program. If the verification is not received no medical expenses will be allowed. |
V009 |
Authorization for Release of Information | This form is sent to the consumer to sign the release of information statement and take to the person or organization who provides the information requested. |
V010 |
Social Security Number Request | This form is sent to the consumer requesting proof of SSN. |
V013 |
Expenses Exceed Income | This form is sent to the consumer to request information regarding a discrepancy in reported net income and reported expenses. Expenses total more than the income reported. |
V026 |
Notice of In-Office Interview Scheduled | This notice is sent to the consumer to provide information regarding an interview to obtain needed verifications for the application or review to be processed. |
V054 |
FA-Simplified Reporter | This form is sent to the consumer to give information regarding reporting requirements for Food Assistance benefits. |
V061 |
FA Simplified Reporter-24 Month Review period | Notice to consumer advising what the reporting requirements are. |
V062 |
FA Simplified Reporter-No IR | Notice to consumer advising what the reporting requirements are. |
V064 |
FA Simplified Reporter – No Reporting Requirement | Notice to consumer advising what the reporting requirements are. |
V103 |
Kansas Benefit Repayment Agreement | Notice to consumer-repayment agreement to have benefits deducted from EBT card. Send the Standard Copy and Paste Text. |
V301 |
Interview Notification | This form is sent to the consumer to request a telephone interview and provides a specific time for the consumer to call the agency. The form also requests other needed information that needs to be faxed or mailed to the agency in order for the application to be processed. |
V801 |
Case Transfer Notice | Notice to consumer that their case has been transferred to a different office. |
V808 |
Message From Your Local DCF Office | This form is used to send general correspondence to the consumer. |
V828 |
Repayment Agreement Reminder All Programs CCU | This form is sent to the consumer as a reminder about the overpayments received. The form provides the overpayment amount by program. |
V829 |
Delinquent Repayment Agreement-CCU | Letter sent to consumer when there is/are unpaid overpayment(s) and the program/case is in other than active status. |
V830 |
Demand Notice at Closure | Letter sent to consumer when there is an unpaid overpayment balance and the program is no longer active. |
V831 |
Unused EBT Benefits Applied to Claim | Letter sent to consumer when an existing overpayment balance is being offset by unused benefits from EBT card. |
V836 |
TANF Months Count Adjustment Notice | Letter to consumer notifying them of the number of TANF months used. |
V837 |
EBT Excessive Card Issuance | Notice informing consumer they have requested and received and excessive number of EBT cards and could be subject to special investigation. |
V838 |
Excessive EBT Manual Entry Transactions | Notify consumers they have too many manual entry transactions on their EBT account. |
W001 |
Work Program Appointment Letter | This form is sent to the consumer to notify the consumer of the appointment date, time and location to discuss their required participation in work program activities. Informs consumer that failure to keep the appointment without good cause results in a penalty. |
W002 |
Review of Activities Appointment | This form is sent to the consumer to schedule an appointment to review their progress in the assigned work activities. |
W101 |
Work Program Activity Assignment Letter | This form is sent to the consumer to provide information about participation in an assigned work activity. |
W106 |
Work Program Request for Good Cause | This form is sent to the consumer after contact has been made that verification for good cause for non-participation in a work activity is needed. The form includes a due date for receipt of the verification. Provides information regarding the penalty for not submitting the verification. |
W108 |
Notice of TANF Months/Hardship Review | This form is sent to the consumer to let them know that someone on the case is reaching the 24-month time limit to receive TANF. It either provides an appointment time or asks the consumer to contact the agency to schedule an appointment. Send the V808 with Standard Copy and Paste Text. |
W358 |
Assessment Notice | This notice is sent to the consumer to provide notification of the work program's assessment appointment. |
W402 |
Employment Letter | This letter is sent to the consumer after they have become employed. The form asks for contact to schedule an appointment or provides the date, time, and location of the scheduled appointment. |
W407 |
Transitional Service Offer | Notice to consumer of possibility of additional services after program closure. |
W408 |
Work Program Penalty Cure Notification | Notice to consumer a person on their case has now cooperated with work programs. |
W455 |
Work Program Referral Letter | Information sent to consumer. |
W503 |
Work Program Request for Information | Sent to consumer - Work Program request for information. |
W504 |
Request For Good Cause | This notice is sent to the consumer as a request for verification of good cause for failure to attend scheduled employment and training activities. The form includes a due date for receipt of the verification and provides information regarding violations for not submitting the verification. |
W806 |
Work Program Payment Approval | Notice to consumer of approval for Work Program payments. |
X001 |
Pregnancy Overdue Notice | Notification sent when a member of the household is pregnant and the due date has past. |
X045 |
Notification of Missed Interview | This form is sent to a consumer after they have missed an interview to determine eligibility for TANF and/or FA. |
X046 |
Food Assistance Replacement Notice | Notifying consumer that, as a result of a recent disaster, their FA is being replaced. |
X088 |
Notice of TANF Months Used | Notice to consumer informing about time limited assistance. Send the V808 with Standard Copy and Paste Text. |