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APPENDIX C1 - COMMONLY USED FORMS

The following is a list and description of the forms most commonly used by ESA. The first set of forms are those which do not have form numbers; these forms are referred to by name or title. The second set of forms are those which have form numbers. ACEDS Verification Checklist - document that informs an applicant what information is needed to determine program eligibility. All applicants from whom information is needed must be given a checklist. If the system is inoperable, issue a 1356 Manual Application Checklist. Original to applicant/recipient, copy in record. Acknowledgment of Paternity - form completed by a father whose name does not appear on the birth certificate (or whose name is on a D.C. birth certificate issued prior to 10/81, but the father was not married to the mother and there has been no adjudication) to establish that the individual is, in fact, the father of the child. Original to CSED, copy in record, copy to father, copy to mother. Combined Application (aka Generic Application) - application used for TANF, GC, IDA, and FS, available in multiple languages. DC Healthy Families Application [PDF] [English] [En Español] - Medicaid application used by families with children. EBT Referral - form completed by SSR to reinstate benefits for a recipient whose EBT account has been closed due to inactivity. Original faxed and filed in case record. Food Stamp Expense Addendum to Generic Application - form completed at application and recertification explaining that dependent and shelter care expenses will not be considered if verification is not provided. Food Stamp Only Application - application usable for Food Stamps only Generic Application (aka Combined Application) - application used for TANF, GC, IDA and FS. Generic Recertification Form - form used to recertify TANF, GC and FS. Immigration and Citizenship Initial Declaration Form - an initial form used to determine household members who are US citizens, nationals or "qualified" immigrants. IV-D Partnership Agreement - form used to notify TANF and Medicaid customers of child support requirements and the good cause reasons for non-cooperation. Notice of Privacy Practices [PDF] [English] [En Español] - form used to notify Medicaid/Medical Assistance customers of their rights pertaining to the release of protected health information and other personal data. Periodic Report - form completed quarterly by employed TANF recipients to report earnings and certain household changes. Preliminary Assessment- form completed by SSR and TANF applicant to assess his/her employability. Original forwarded, copy in record, copy to applicant/recipient. Rental Vendor Referral Form - form used to refer a TANF applicant/recipient for rental vendor payment. Original forwarded, copy in record.