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Page | 51 Part H- Attachments

ATTACHMENT NO.

DOCUMENT TITLE Attachment A – 1

DHS Organizational Chart Attachment A – 2

Form DHS 1240, Application for Financial and SNAP Assistance Attachment A – 3

Brochure, How to Use Your Kokua EBT Card

Attachment B – 1

Form DHS 1259, TANF Work Program Referral and Requirements Attachment B – 2

Form DHS 1242, TANF Memorandum of Understanding (MOU) Attachment B – 3

Form DHS 1260, TANF Self-Declaration Screening Form to Claim Domestic Violence Status Attachment B – 4

Form DHS 1247, Notice of Requirement to Cooperate with Child Support Enforcement Agency and Right to Claim Good Cause

Attachment C – 1

Child Care Rate Table Attachment C – 2

Form DHS 736, First-To-Work Program Education, Vocational Training and Work-Related Expenses Attachment C – 3

Form Child Care Gross Income Eligibility Limits and Sliding Fee Scale Attachment C – 4

Form DHS 737, First-To-Work Program One-Time Training and Work-Related Expenses for Individuals Exiting TANF Due to Employment

Attachment D – 1

Acronyms