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107 Verification of Household Composition - form that can be used to verify household membership. 107 Financial Verification Statement - form that can be used to verify income. 107 Referral to APRA/POWER - form used to refer POWER recipients to the Addiction Prevention and Rehabilitation Administration for substance abuse treatment or counseling. Original to recipient, copy in record. 107 Referral to RSA/POWER - form used to refer POWER recipients to the Rehabilitation Services Administration. Original to recipient, copy in record. 107 Referral for Domestic Violence Services - form used to refer TANF applicant/recipient to the Domestic Violence Unit. FNS 387 Food Stamp Change Report Form - form given to applicant/recipient to report interim changes to the Agency. Forms submitted by the recipient to report a change are kept in the case record. 495 Authorization for Investigation - form signed by applicants to authorize the agency to seek information from collateral contracts. Required for all MA, TANF, GC and FS cases (except by those applicants/recipients who use the DC Healthy Families application). Original and copy in record. 495-ARI Release of Information [PDF] - form used by the customer to authorize the release of information, included protected health information to a third party. 496-COA Change of Address - form used by Medicaid/Medical Assistance customers to report change of address. 726 Report of Overpayment - form used to report TANF overpayments to OIC and identify amount to be recouped. Original to recipient, copy in record, copy to Special Services. 854 Social Information-Medical Review - form completed by MA and TANF applicant/ recipient and their SSR to determine incapacitation/disability in cases in which the applicant/recipient claims to be disabled or incapacitated. Original to MRT, copy in record. 856 Medical Examination Report [PDF] - form completed by applicant's/recipient's physician which is used to determine incapacitation/disability. Original to MRT, copy in record. 886 Information Exchange - form used when there is formal exchange of information within ESA or between ESA and other DC government entities. Original forwarded, copy in record. 886- Waiver Notification of New Medicaid Waiver Case - form used by the Medicaid Branch to communicate to SSRs in a Service Center that one of their current customers has enrolled in a Medicaid Waiver program. 886- Ward* Notification of District Ward Status [PDF] - form used by the Medicaid Branch to communicate to SSRs in a Service Center that one of their current customers has been declared to be a ward of the District.