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Eligibility Management (Income Maintenance) Home >> IM Forms

Caretaker Supplement Forms by Form Title

Last Revised: March 26, 2014

This list contains all Caretaker Supplement program forms that are available from DHCAA. 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 Title Form Number Form Type Revised Date Language
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 (CTS) Instructions for Application - Spanish (PDF, 54 KB) F-22571AS PDF 7/1/2008 Spanish
Caretaker Supplement Application (PDF, 218 KB) F-22571 PDF 7/1/2008 English