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Page | 42 211 Authorization to Release Information Used if the applicant wants the Department to release information to an entity outside of DSS. 214 Report Form A form used by households required to submit a 6 month report. It is used to report income, expenses, household composition, and changes in resources. 214R 214 Reminder Notice A notice that is sent to households on the 15th of the month if the complete EA-214, six month report form, was not received. 221A Family Assessment Form A form designed to solicit information to determine individual or family needs, identify barriers to self- sufficiency, and offer guidance for suitable referrals. Instructions for use of this form are listed on the p drive, 221A Instructions. 231 Child Support Enforcement Referral A form required by the head of household who has a child that does not have a parent living in the home. This is a required form to be completed by the head of household and is then sent to DCS. 232 Notice of Requirement to Cooperate with DCS An acknowledgment form that must be signed by the head of household who has a child that does not have a parent living in the home, stating they must cooperate with DCS on information about the parent not in the home. 233 Good Cause for Refusal to Cooperate with DCS A form to allow the head of household to claim good cause for not cooperating with DCS on information about the parent not in the home. 241 Lease Income Verification A letter sent to tribal entities to verify the amount of lease income a household may receive from July to June of a particular year. 267 Bank Letter Letter used to obtain balances for bank accounts at a particular facility. 269 Child Care Expense Used to verify the amount and frequency of child care expense that is billed to a household. 274 Request for SSN A form used to verify that a SSN has been applied for at the Social Security Administration. 300 Cover Letter and Verification Checklist A cover letter and form used to advise customers of needed documents to complete the application or review process. 301 Economic Assistance Application The application used to apply for SNAP and Medical Assistance.

301I Improved Nutrition (IN) Program Application Application form used by individuals or couples who receive SSI to apply for the simplified SNAP program (IN) 306 306O 306P Renewal Notice Office and Phone Renewal Notices sent to households that are due for renewal. The 306 O & 306P can be sent to households that did not have an automated notice generated. 307 SNAP Exit Form A form used by drug and alcohol facilities or Community Support Provider facilities to report when a resident has left their facility.