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West Virginia Income Maintenance Manual Acronyms, Forms, and Glossary

West Virginia Income Maintenance Manual Page 20

Acronyms, Forms, and Glossary

Form Abbreviation/Code Form Name Chapter (s) DFA-ADA-1 Referral Form for Accommodations for the Disabled 1 DFA-ADA-1A Follow-Up to DFA-ADA-1 1 DFA-ADARA-1 ADA Reasonable Accommodation Request Form 1, 18 DFA-AP-1 Acknowledgement of Automatic Assignment of Support Rights and of Cooperation Requirements 1, 18 DFA-AP-1A Notice to Individual Who Has Claimed Good Cause for Refusal to Cooperate in Child Support Activities 1, 18 DFA-B-13 Eye Exam - Physician Report 13 DFA-B-13a Report on Eye Examination 13 DFA-BCC-1 BCC Application 1 DFA-BU-1 Application for Burial Benefits 1, 20 DFA-BU-2 Affidavit of Responsible Relative 1, 20 DFA-BU-3 Affidavit of Burial Costs and Supporting Documentation 20 DFA-BU-4 Indigent Burial Application 20 DFA-CARS-1 Donated Vehicle Program Referral 18 DFA-CI-1 Release of Confidential Information 1 DFA-CWEP-1 CWEP/JOIN Individual Participation Agreement 18 DFA-CWEP-3 CWEP/JOIN Contract with Attachments 18 DFA-CWEP-3A CWEP/JOIN Addendum/Renewal 18 DFA-DIMA-1 Disability/Incapacity Med. Assessment 7, 13, 14 DFA-EA-1 Application for Emergency Assistance 1, 20 DFA-EIP-1 Employer Incentive Program Agreement 18 DFA-ESP-1 ESP Agreement 18 DFA-ESP-1a Employment Subsidy Program Agreement 18 DFA-ESP-2 Employer Reimbursement Request 18 DFA-EX-1 Extension Request Form 18 DFA-FH-1 Pre-Hearing Conference and/or Fair Hearing Request 9, 20, 24 DFA-FS-19 Notification of Denial of Expedited Service (SNAP Only) 9