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West Virginia Income Maintenance Manual Acronyms, Forms, and Glossary

West Virginia Income Maintenance Manual Page 19

Acronyms, Forms, and Glossary

FORMS The following is a list of forms commonly found throughout the West Virginia Income Maintenance Manual (IMM). Additionally, the chapter(s) in which the forms are referenced are identified. The form names reflect the names used in the IMM. Form Abbreviation/Code Form Name Chapter (s) BA-67 WVTS Voucher 5, 12, 18 CSHCN-1 Children with Special Healthcare Needs Application 1, 23 CSLE SNAP Review Form - CSLE 1 CSLR SNAP and Medicaid Review Form 1 CWN-1 Consolidated Work Notice 1, 9, 14 DF-25 Financial Document 11 DF-36 Lost Check Affidavit 12, 21 DF-68 Remittance Form 18, 20 DF-622 Authorization for Payment 21 DFA-2 Application for Benefits 1, 9, 10, 19, 20, 21, 23, 24 DFA-4 Appointment Letter 9 DFA-5 Document for Protection of Application Date 1, 9, 19, 20, 24 DFA-6 Request for Additional Information 1, 2, 4, 6, 7, 9, 10, 18, 20, 24 DFA-6A Spenddown Explanation 4, 9, 24 DFA-10 Appointment Letter for Office, Home, Phone 9, 24 DFA-17 Work Record Sheet 7 DFA-20 Application Not Acted On Letter 1, 9, 13 DFA-22 Agreement to Sell Property 5, 7 DFA-36B Request for Replacement of Stolen SNAP & WV WORKS Benefits 12 DFA-67 Authorization for Payment 20, 21 DFA-67-A Burial Billing Form 20