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PB Home  Back to Documents: 2009 Policy Bulletins    
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Documents: 2009 Policy Bulletins

#09-12-OPE: Revisions To Selected FIA Forms
(This Policy Bulletin Replaces PB #99-23 and Obsoletes PB #02-210-EMP)

The purpose of this policy bulletin is to inform all Job Center staff that the following forms have been revised to conform to the Agency’s formatting standards and current terminology.
The forms will also be translated to comply with Local Law 73 requirements. Under Local Law 73, applicant/participant notices that may affect benefits must be translated into Arabic, Chinese, Haitian Creole, Korean, and Russian.
• Agreement to Repay Cash Assistance (M-15f)
• Certification for Retroactive Medicaid Coverage (M-42q)
• Notice to Recipient 62 Years of Age (M-50j)
• Request for Shelter Payment to an Alcohol Crisis Center ACC) for Individuals with an Active Cash Assistance Case M-74h)
• Consent for Release of Information to an Employment Vendor Concerning Alcohol/Drug Abuse Patient (M-75p)
• Plan of Self-Support Agreement for Medicaid (M-696b)
• Plan of Self-Support Agreement for Cash Assistance M-696c)
• CASAC Reassessment (W-532N)
• Questionnaire on Availability of Health Insurance Coverage at Place of Employment (W-560C)
• Application for Child-Only Cash Assistance Child Care Payments (W-560ZZ)
• Applicant’s Task List (W-680F).


Created: 2/23/2009