Caretaker Supplement Forms

Clicking the Assigned Number link will either download the selected form (if only one version is available) OR it will open a page that will display all language versions of that form. From that page you can choose and download the needed forms.
Assigned Numbersort descending Title Division Other Location
F-00107 Self-Employment Income Report (PDF, 91 KB) DHCAA
F-00107W Self-Employment Income Report Worksheet (PDF, 32 KB) DHCAA
F-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate (PDF, 279 KB) DHCAA
F-22564 Authorization for Retroactive Caretaker Supplement (CTS)* (PDF, 28 KB) DHCAA
F-22565 Authorization for Recoupment Caretaker Supplement DHCAA
F-22571 Caretaker Supplement Application (PDF, 218 KB) DHCAA
Last Revised: December 19, 2014