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Appendix 6

Glossary of Forms THE FOLLOWING FORMS AND LETTERS ARE FOR REFERENCE ONLY Please consult the Master Forms Index for the original form

DSS Form 1105-1 Authorization Agreement and Enrollment Form for Electronic Vendor Payment and Remittance Advice DSS Form 1245 Request for Wage Information DSS Form 1245 Spanish Request for Wage Information (Spanish version) DSS Form 1247 Medical Release/Physician’s Statement DSS Form 127-SPA Medical Release/Physician’s Statement (Spanish version) DSS Form 1269 Request for Support Services DSS Form 3004 CPS/Foster Care Child Care Referral Form DSS Form 3772 Client Rights and Responsibilities DSS Form 3772 SPA Client Rights and Responsibilities (Spanish Version) DSS Form 3774 FFN Child Care Enrollment and Agreement Form DSS Form 3775 Non-Related FFN Application for Consideration of Enrollment DSS Form 3776 FFN Child Care Certification DSS Form 3778 Health and Safety Grant Reimbursement Grant DSS Form 3791 Child Care Scholarship Program Application DSS Form 3791-SPA Child Care Scholarship Program Application (Spanish version) DSS Form 3791 A Child Care Scholarship Program Special Needs Addendum DSS Form 3792 Client Connection Form DSS Form 3792 SPA Client Connection Form (Spanish Version)