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Eligibility Management (Income Maintenance) Home >> IM Forms

Caretaker Supplement Forms by Language

Last Revised: March 26, 2014

This list contains all Caretaker Supplement program forms that are available from DHCAA sorted by the language in which they are written. 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.

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