Forms Listing

474-000-401

Form #	Form Title	Appendix Reference
ASD-19	Client Referral	474-000-11
DA-100	Application for Assistance	474-000-15
DA-100A	Supplement to the Application for Assistance	474-000-16
DSS-2A	Social Service Exception	474-000-29
DSS-3A	Social Services Title XX Application	474-000-30
DSS-4	Case Information Summary	474-000-33
DSS-4B	Child Care Notice and Authorization	474-000-200
DSS-5	Authorization and Billing Document	474-000-38
DSS-5B	Social Services Billing Document	474-000-201
DSS-6	Client's Notice of Action	474-000-37
DSS-9B	Child Care Provider Agreement	474-000-202
DSS-10	Social Service Provider Identification	474-000-41
DSS-16	Letter to Client Regarding Child Care Services	474-000-42
DSS-17	Attendance Report for Group Child Care Homes and Child Care Centers	474-000-52
DSS-18	Attendance Report for In-Home and Child Care Home Providers	474-000-53
DSS-112	Letter to Client when there is an abuse report on provider	474-000-203
DSS-113	Letter to provider when there is an abuse-neglect investigation	474-000-204
DSS-114	Letter to client when the provider is on Central Registry	474-000-205
DSS-115	Letter to provider when his/her name is on Central Registry	474-000-206
DSS-0350	In-Home Day Care Self-Certification Checklist	474-000-49
DSS-0351	Approved Family Day Care Self-Certification Checklist	474-000-50

(Rev. May 15, 1998)