Current through Reg. 50, No. 187; September 24, 2024
The following forms are used for Public Assistance Programs
to provide applicants and recipients with required notice of the agency's and
client's rights and responsibilities and other necessary program information.
These forms are hereby incorporated by reference.
(1) Forms that apply to two or more public
assistance programs are:
(a) CF-ES Form 1007,
Oct 05, Office of Appeal Hearings Hearing Request
(b) CF-ES Form 2064, Mar 12, Your Rights and
Responsibilities
(c) CF-ES Form
2304, Sep 02, Public Assistance Consent to Release Information
(d) CF-ES Form 2305, Oct 05, Relative
Caregiver Program Request for Eligibility Consideration
(e) CF-ES Form 2332, Mar 05, Appointment
Notice for Face-to-Face Interview
(f) CF-ES Form 2333, Mar 05, Eligibility
Redetermination Letter
(g) CF-ES
Form 2334, Mar 05, Request for Information
(h) CF-ES Form 2335, Mar 05, Request for
Information for Elderly and Disabled Individuals
(i) CF-ES Form 2336, Nov 06, Interim Contact
Letter
(j) CF-ES Form 2640, May 05,
Temporary Cash Assistance (TCA)/Medicaid/Food Stamp Program Child Support
Cooperation Notice
(k) CF-ES Form
2641, May 05, Claim Notice - Good Cause for Refusal to Cooperate
(l) CF-ES Form 2672, Oct 05, Real Property
Agreement
(m) CF-ES Form 3052A, Feb
09, Change Report Form
(n) CF-ES
Form 3103, Sep 02, Authorized Benefit Representative for Electronic Benefit
Transfer
(2) The Food
Stamp Program only forms are:
(a) CF-ES Form
2095, May 05, Food Stamp Work Registration Notice
(b) CF-ES Form 2331, Jan 05, Food Stamp
Application for SSI Applicants
(c)
CF-ES Form 3010, Feb 09, Authorized Representative
Designation
(3) The
Medicaid only forms are:
(a) CF-ES Form 990,
Sep 02, Designation of Beneficiary
(b) CF-ES Form 1056, Feb 03, KidCare Program
Notice of Case Action
(c) CF-ES
Form 2039, Apr 03, Medical Assistance Referral
(d) CF-ES Form 2040, Feb 03, Informed Consent
Form
(e) CF-ES Form 2059, Sep 02,
Consent of Disclosure Statement
(f)
CF-ES Form 2099, Jul 02, Medicaid Application for Breast and Cervical Cancer
Treatment
(g) CF-ES Form 2277, Oct
05, KidCare Program Medicaid Eligibility Review
(h) CF-ES Form 2293, May 10, Child in Care
Medicaid Application
(i) CF-ES Form
2514, Jul 03, Authorization to Release Medical Information
(j) CF-ES Form 2613, Oct 05, Financial
Information Release
(k) CF-ES Form
2635, Sep 02, Protective Payee Agreement
(l) CF-ES Form 2700, May 10, Health Insurance
Application for Pregnant Women
(m)
CF-ES Form 2701, Feb 03, Request for Length of Treatment Information
(n) CF-ES Form 2930, Apr 07, Screening for
Expedited Medicaid Appointment
(4) The Overpayment and Benefit Recovery only
forms are:
(a) CF-ES Form 3400, Feb 2018,
Request for Additional Information
(b) CF-ES Form 3410, Feb 2018, Waiver of
Administrative Disqualification Hearing With a Program Loss
(c) CF-ES Form 3410A, Feb 2018, Waiver of
Administrative Disqualification Hearing Without a Program Loss
(d) CF-ES Form 3414, Nov 07, Disqualification
Consent Agreement
(e) CF-ES Form
2338, Feb 2018, Contact Notice
(f)
CF-ES Form 2339, Feb 2018, Request for Verification
(g) CF-ES Form 2340, Feb 2018, Home Visit
Confirmation Notice
(5)
The Temporary Cash Assistance only forms are:
(a) CF-ES Form 2082, Sep 05, Hardship
Extension/Exemption Review
(b)
CF-ES Form 2094, Jun 09, Statement of the Need for Care
(c) CF-ES Form 2097, Oct 05, Communication
and Work Activity Referral
(d)
CF-ES Form 2299, Feb 03, Alcohol, Drug Abuse and Mental Health (ADM) Treatment
Verification
(e) CF-ES Form 2601,
Feb 03, Temporary Cash Assistance Program Refugee Assistance Program
(f) CF-ES Form 4192, May 05, Notice of Work
Penalty
The edition date on some forms is listed with a notation that
the edition replaces a previous edition that may still be used. This notation
is to indicate that the new edition of the form does not implement a policy
change and that supplies of the previous edition of a specific form may be
exhausted prior to the use of the new edition.
(6) Copies of materials incorporated by
reference are available from the Florida Department of Children and Families,
Office of Public Benefits Integrity, 2415 North Monroe Street, Suite 400,
Tallahassee, FL 32303-4190, or on the Department's website at
http://www.dcf.state.fl.us/DCFForms/Search/DCFFormSearch.aspx.
Forms CF-ES 3410, CF-ES 3410A, CF-ES 2338, CF-ES 2339, and CF-ES 2340 can also
be found at
http://www.flrules.org/Gateway/reference.asp?No=Ref-09355;
http://www.flrules.org/Gateway/reference.asp?No=Ref-09356;
http://www.flrules.org/Gateway/reference.asp?No=Ref-09357;
http://www.flrules.org/Gateway/reference.asp?No=Ref-09358;
and http://www.flrules.org/Gateway/reference.asp?No=Ref-09359,
respectively.
Rulemaking Authority
409.919,
410.033,
414.45 FS. Law Implemented
409.903,
409.904,
410.033,
414.065,
414.075,
414.085,
414.095,
414.105,
414.115,
414.122,
414.31
FS.
New 4-9-92, Amended 7-1-93, 8-3-94, Formerly 10C-1.400,
Amended 12-29-98, 3-18-03, 7-25-06, 1-8-12,
6-4-18.
