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Eligibility Management (Income Maintenance)
Home >> IM Forms
Non-Division of Health Care Access and Accountability (DHCAA) EM Forms
This page contains links to forms maintained by the Department of
Workforce Development (DWD) or other non-DHS agencies that are needed
by Eligibility Management workers.
See About PDF
Forms for more information on using PDF files.. 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.
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F-20919
(PDF, 18KB)
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Medicaid
Waiver Eligibility and Cost Sharing Worksheet |
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F-20919D
(PDF, 28KB)
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Declaration
Regarding Transfers of Resources |
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G 845
(exit DHS)
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Document
Verification Request (SAVE Agencies) |
| G
845 Supplement
(exit DHS)
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Document
Verification Request Supplement (SAVE Agencies) |
| F-09002 (FNS 135)
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Affidavit
of Return or Exchange of Food Coupons |
F-82009
(Word, 43KB)
DHS Word Document |
Confidential
Information Release Authorization |
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Last Revised:
February 23, 2011
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