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Eligibility Management (Income Maintenance) Home >> IM Forms

Non-Division of Health Care Access and Accountability IM 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.

F-20919 (PDF, 18KB) Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-20919D (PDF, 28KB) Declaration Regarding Transfers of Resources
G 845 (exit DHS) Document Verification Request (SAVE Agencies)
G 845 Supplement (exit DHS) Document Verification Request Supplement (SAVE Agencies)
F-09002 (FNS 135)  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: March 26, 2014