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Eligibility Management (Income Maintenance) Home >> IM Forms

Caretaker Supplement Forms by Form Type

Last Revised: March 26, 2014

This list contains all Caretaker Supplement program forms that are available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF- Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language
PDF Authorization for Recoupment Caretaker Supplement (CTS)* (PDF, 14 KB) F-22565 7/1/2008 English
PDF Authorization for Retroactive Caretaker Supplement (CTS)* (PDF, 28 KB) F-22564 7/1/2008 English
PDF Caretaker Supplement (CTS) Instructions for Application (PDF, 47 KB) F-22571A 7/1/2008 English
PDF Caretaker Supplement (CTS) Instructions for Application - Spanish (PDF, 54 KB) F-22571AS 7/1/2008 Spanish
PDF Caretaker Supplement Application (PDF, 218 KB) F-22571 7/1/2008 English
Word Authorization for Recoupment Caretaker Supplement F-22565 7/1/2008 English