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Appendix A - Application Forms Attachment A- Included Income Attachment B- Excluded Income Attachment C- Wage Verification Form Attachment D- Request for Additional Information Attachment E- Social Security Number Verification Attachment F- Proof of Residence Attachment G- Request for Fair Hearing Attachment H- Withdrawal Request for Fair Hearing Attachment I- Overpayment Letter #1 Attachment J- Overpayment Letter #2 Attachment K- Overpayment Letter #3 Attachment L- Overpayment Letter with IPV #1 Attachment M- Promissory Note and Confessed Judgment form Attachment N- Administrative Disqualification Hearing Waiver Attachment O- Disqualification Consent Agreement Attachment P-Administrative Disqualification Hearing Pamphlet Attachment Q- Notice of Administrative Disqualification Hearing Decision Attachment R- Consent to Release of Information Form Attachment S- Point in Time Waiver Attachment T- Physician Certification (PC) form Attachment U- DHCD form. Attachment V- Crisis Season Declaration Form Attachment W- OAH’s Transmittal for Department of Human Resources form Attachment X- Logon Request Form Attachment Y- FIA Document Disposal guidelines

Updated May 2025