please assist us by answering the questions below and returning this form to us by _____ . _____ Case Name _____ Case Number/Cat/Seq. Office Address / Phone Number: Please complete each section which has been marked on Page 1 AND Page 2 of this form. Section I – GENERAL INFORMATION ...
Forms . Page 1 of 1 Forms - Numerical Index Alphabetical Forms Index Children & Families. 505 Hudson Street Hartford CT 06106 About CT; Policies; Accessibility; Directories; Social Media; For State Employees; United States Mast: (Half) Connecticut ...
Forms Search To find DCF Publications, please go to the publications search page.. Below is a searchable list of forms used by programs and DCF staff. The table can be searched via title, number, and language or by scrolling through the complete list.
Applying for government assistance benefits is free. Clients can apply online for free by using the Office of Economic Self Sufficiency Self Service Portal or by visiting a DCF Community Partner. If you believe you have been charged a fee inappropriately or have suspected fraud to report, please do so here.
Date . Signature : Witness if signed with an X . Witness if signed with an X : Request For Waiver Of Food Assistance Office Application Interview . I am unable to appoint an authorized representative or have an adult member of my household attend the food
If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. You may request the application form from a DCF office in person, or call 1-888-369-4777 to have one mailed to you. You may also elect to apply ...
Form Approved DCF No. CF-ES 2370, Sep 2015 [65A-1.205, F.A.C.] Use this application to see what coverage choices you qualify for • Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP) • Affordable private health insurance plans that offer comprehensive coverage to help you stay well
You must submit this form along with any documentation that verifies your household lost food due to a power outage (4 or more hours) or damage due to a fire or natural disaster. The form must be submitted within 10 days from the date of the food loss. Recipient Name: _____
Use of form: Use of this form is voluntary. This form may be used by Family Child Care Centers to ensure compliance with DCF 250.04 (6) (b) and 250.05 (2) (c), by Group Child Care Centers to ensure compliance with DCF 251.04 (6) (b) and 251.05 (2) (a) 6., by Day Camps for Children to ensure compliance with DCF 252.41 (4)
This authorization form must be maintained and is only valid for the duration of prescription. I hereby give permission to dispense the medication(s) listed above in accordance with the written directions on the prescription label or printed manufacturer's label. Parent/Guardian Signature Date (Retain in child's file for a minimum of four months)
Forms are available for view in either or both of the following formats: Adobe Acrobat (pdf) MS Word for Windows (doc) Tenga en cuenta que los formularios enumerados están en inglés. Si necesita un . This page includes all DCFS forms available online. Forms are available for view in either or both of the following formats: Adobe Acrobat (pdf ...
Get all DCF forms 1 to 5000+, including: DCF-136: Report Child Abuse and Neglect.. DCF-2131: Authorization for Release of Information DCF-737: Notification to State/Local Police of Suspected Child Sexual Abuse, Severe Physical Abuse, and/or Neglect DCF-823: Exceptional Circumstances form DCF-465: Psychotropic Medication Consent Requests Change Form for Children
for the release of information about certain conditions and from educational sources. You can provide this authorization by signing a form CF-ES 2514. Federal law permits sources with information about you to release that information if you sign a single authorization to release all your information from all your possible sources.
The form is due no later than 10 days after the date of the loss. Mailing address: DCF Family Resource Center 2810 Sharer Road, Suite 25 Tallahassee, FL 32303 Fax: (866) 886-4342 For faster processing, please return completed form in-person at the address listed above OR your local DCF Family Resource Center. CF-ES 3515, PDF 07/2012
(Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. •Section 7.3 of the Child Care Facility Handbook requires that parents receive a copy of the Child Care Facility Brochure entitled “Know Your Child Care Facility” (CF/PI 175-24) [also available on-line at
