ECONOMIC & EMPLOYMENT SUPPORT
|
Item Number |
Revised
Date |
PROGRAM SECTION |
File
Format |
ES-524 |
05-08 |
Food Stamp Disqualified Recipient Report |
DOC |
PDF |
ES-1510.1* |
04-09 |
Computation of Food Stamp Benefit Instructions |
XLS |
PDF |
|
ES-1512 |
07-03 |
Change Report Form |
DOC |
PDF |
|
ES-1600* |
10-02 |
Civil Rights Complaint |
DOC |
PDF |
|
ES-1602* |
10-04 |
Child Care Provider Rate Modification |
DOC |
|
|
ES-1604* |
05-05 |
Daily Attendance Record (Sample Form) |
DOC |
PDF |
ES-1605 |
09-05 |
Child Care Subsidy Audio Response Unit (ARU) Worksheet |
DOC |
PDF |
ES-1606* |
01-07 |
Request for Supervisory Approval - Child
Care Exceeding 215 Per Month |
DOC |
PDF |
|
ES-1611* |
12-05 |
Request for SRS Child Care Assistance at Flint Hills Job Corps
Child Development Center |
DOC |
PDF |
|
ES-1627* |
01-06 |
Request for Social Service Child Care |
DOC |
PDF |
ES-1627a* |
07-08 |
Request for Enhanced Rate for Special Care |
DOC |
PDF |
|
ES-1640* |
01-05 |
Statement of Understanding - Employed Income Eligible Child
Care Assistance |
DOC |
PDF |
ES-2001 |
09-06 |
EES Programs Brochure (Help for Working Families) |
|
PDF |
ES-2001S |
10-06 |
EES Programs Brochure (Help for Working Families) (Spanish) |
|
PDF |
| ES-2002 |
05-09 |
Medicare Savings Plan (MSP) |
|
PDF |
ES-2002S |
05-09 |
Medicare Savings Plan (MSP) Brochure (Spanish) |
|
PDF |
ES-2007 |
10-08 |
Food Assistance Brochure
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Arabic)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Farsi)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (German)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Hmong)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Lao)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Russian)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Somali)
|
Insert 2008 |
PDF |
ES- 2007 |
10-08 |
Food Assistance Brochure (Spanish) |
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Swahili)
|
Insert 2008 |
PDF |
ES-2007* |
10-08 |
Food Assistance Brochure (Vietnamese)
|
Insert 2008 |
PDF |
ES-2008 |
10-05 |
Need a Little Extra Dough |
|
|
ES-2008SP |
10-05 |
Need a Little Extra Dough (Spanish) |
|
|
ES-3100 |
01-09 |
Application for Cash, Medical, Child Care and Food Stamp Benefits for Families |
|
PDF |
ES-3100 |
02-09 |
Application for Cash, Medical, Child Care
and Food Stamp Benefits for Families (PDF) : Arabic, Farsi, German, Hmong, Lao, Russian, Somali, Spanish, Swahili, Vietnamese |
ES-3100.1 |
01-09 |
Application for Cash, Medical, and Food Stamp Benefits for Elderly and Disabled |
|
PDF |
ES-3100.1 |
02-09 |
Application for Cash, Medical, and Food Stamp Benefits for Elderly and Disabled (PDF): Arabic, Farsi, German, Hmong, Lao, Russian, Somali, Spanish, Swahili, Vietnamese |
ES-3100.4 |
01-08 |
Obsolete |
ES-3100.4a |
01-08 |
Obsolete |
|
ES-3100.5 |
10-00 |
OBSOLETE |
|
|
|
ES-3100.6 |
05-08 |
Obsolete |
ES-3100.6-S |
05-08 |
Obsolete |
|
ES-3100.7* |
10-01 |
Application for Medical Coverage - Breast and Cervical Cancer |
DOC |
PDF |
ES-3100.8 |
12-08 |
Application/Redetermination
Medicare Savings Plans |
|
PDF |
ES-3100. 9 |
06-09 |
Grandparents as Caregivers Assistance Application |
|
PDF |
ES-3100. 9 |
06-09 |
Grandparents as Caregivers Assistance Application Arabic, Farsi, German, Hmong, Lao, Russian, Somali, Spanish, Swahili, Vietnamese |
ES-3101* |
05-07 |
Release of Information and Liability |
DOC |
PDF |
ES-3102* |
01-07 |
Important Information About Cooperation |
DOC |
PDF |
ES-3102S* |
10-04 |
Important Information About Cooperation
(Spanish) |
DOC |
PDF |
ES-3103* |
10-08 |
Income/Expense Worksheet Instructions |
XLS |
|
ES-3104.1 |
01-09 |
TAF Benefit Determination Instructions |
XLS |
|
|
ES-3104.5* |
05-09 |
Determination of Need (Medical Assistance) |
DOC |
PDF |
|
ES-3104.6* |
01-09 |
Determination Worksheet for PICKLE Eligibles and Other
Protected Medical Groups |
DOC |
PDF |
|
ES-3105.3 |
07-03 |
An Important Reminder From SRS |
|
PDF |
|
ES-3105.4 |
07-03 |
Acknowledgement of Reporting Responsibilities |
DOC |
PDF |
ES-3105.4S |
07-03 |
Acknowledgement of Reporting Responsibilities (Spanish) |
DOC |
PDF |
|
ES-3106* |
10-99 |
Notice of Action (Copy current Back
of Notice from Appendix when using this notice.) |
DOC |
PDF |
|
ES-3107* |
10-99 |
Waiver of Timely Notice of Action |
|
PDF |
ES-3108* |
05-08 |
Appointment of Authorized Medical Agent for a Minor |
DOC |
PDF |
| |
|
ES-3113A* |
05-00 |
Eligibility Documentation Log |
DOC |
PDF |
ES-3114 |
10-05 |
Food Stamp Interim Report Form |
DOC |
PDF |
ES-3114-S |
10-05 |
Food Stamp Interim Report Form |
DOC |
PDF |
ES-3115* |
10-08 |
SSI 12 Month Report Form |
DOC |
PDF |
ES-3115* |
10-08 |
SSI 12 Month Report Form(pdf) Russian |
|
ES-3118 |
06-99 |
Quality Enhancement Review (Family Programs) |
|
PDF |
|
ES-3119 |
06-99 |
Quality Enhancement Review (Elderly/ Disabled Programs) |
|
PDF |
|
` |
` |
Instructions for Quality Enhancement Review Forms |
|
PDF |
|
ES-3120* |
10-99 |
Initial Interview and/or Referral |
DOC |
PDF |
ES-3141 |
06-05 |
Vision Card Request for Alternate Payee |
DOC |
PDF |
ES-3142* |
01-08 |
EBT Benefit Repayment Agreement |
DOC |
PDF |
ES-3143* |
|
Food Stamp Replacement During Household Disasters |
DOC |
PDF |
ES-3151 |
01-07 |
Obsolete |
ES-3152* |
10-04 |
Medical Assistance Lien Physician Verification |
DOC |
PDF |
ES-3153 |
05-05 |
Statement of Continuing Eligibility (Working
Healthy) |
DOC |
PDF |
|
ES-3160 |
07-07 |
Notification of Medicaid/HCBS Services Referral/Initial
Eligibility/Assessment/ Services Information |
DOC |
PDF |
|
ES-3161 |
07-07 |
Notification of Medicaid/HCBS/Working Healthy Services |
DOC |
PDF |
|
ES-3162* |
01-09
|
Resource Assessment and Allowance Determination Form |
DOC |
PDF |
|
ES-3163* |
05-09 |
Income Allowance Determination Form |
DOC |
PDF |
|
ES-3164* |
05-04
|
Request of CARE Information/Level if Care Score |
DOC |
PDF |
* |
07-04 |
Instructions for Request and Use of the ES-3164 |
|
|
|
ES-3165* |
05-09 |
Working Healthy and Premium Information |
DOC |
PDF |
|
ES-3166* |
01-07 |
Notification of PACE Information |
DOC |
PDF |
ES-3167 |
01-08 |
Annuity Information -
Kansas Medical Assistance Program |
DOC |
PDF |
ES-3167A |
05-07 |
Annuity Information Request |
DOC |
PDF |
ES-3170* |
10-03 |
Beneficiary/Patient Spenddown Billed Form |
DOC |
PDF |
|
ES-3175* |
10-99 |
Obsolete |
|
ES-3176* |
10-99 |
Obsolete |
| ES-3178 |
07-09 |
Authorization Form for the Release of Information |
|
PDF |
|
ES-3500 |
11-08 |
Low Income Energy Assistance Program Application (LIEAP)
|
DOC |
PDF |
ES-3500S |
11-08 |
Low Income Energy Assistance Program Application
(LIEAP) (Spanish) |
DOC |
PDF |
ES-3820 |
05-06 |
Notice of Eligibility Review |
DOC |
PDF |
ES-3820S* |
05-03 |
Notice of Eligibility Review (Spanish) |
DOC |
PDF |
|
ES-3821* |
10-00 |
Notice of Eligibility Review (HealthWave/Medicaid) |
|
PDF |
ES-3822* |
07-06 |
Notice of Review -
Medical Assistance - BCC Program |
DOC |
PDF |
ES-3822A* |
07-06 |
Statement of Continuing Cancer Treatment
Medical Assistance - BCC Program |
DOC |
PDF |
ES-3850* |
01-08 |
Record of Identity and Citizenship Documentation |
DOC |
PDF |
ES-3900* |
10-06 |
Tell Us If You Have A Disability |
DOC |
PDF |
ES-3901 |
10-06 |
Presumptive Medicaid Disability Determination Referral Form |
DOC |
PDF |
ES-3902 |
10-06 |
Presumptive
Medical Disability |
|
PDF |
ES-3903 |
10-06 |
Presumptive Medical Disability Determination
Telephone Consultation Guide
|
DOC |
PDF |
ES-3904 |
10-06 |
HIPAA Compliant Authorization to Release Information to Kansas Health Policy Authority |
DOC |
PDF |
ES-3905* |
10-06 |
General Assistance and MediKan Review Requirements |
DOC |
PDF |
ES-3906* |
10-06 |
Presumptive Medicaid Disability Determination Notification of Changes and Final Decision Form |
DOC |
PDF |
ES-3907* |
10-06 |
Disability Review Team Referral |
DOC |
PDF |
ES-3908 |
10-06 |
Referral
to Kansas Legal Services |
DOC |
PDF |
ES-4104* |
10-06 |
Cooperative Work Site Agreement |
DOC |
PDF |
ES-4104.1* |
10-06 |
Work Experience Program Agreement (Addendum) |
DOC |
PDF |
ES-4105* |
02-07 |
Cooperative Community Service Program Agreement |
DOC |
PDF |
ES-4105.1* |
10-06 |
Cooperative Community Service Program Agreement (Addendum) |
DOC |
PDF |
ES-4304 |
10-08 |
TAF Work Hours Verification Checklist |
DOC |
PDF |
ES-4305 |
11-08 |
TANF Sample Cases Review Guides |
DOC |
PDF |
ES-4306* |
10-08 |
Employer Contact Record |
DOC |
PDF |
ES-4309* |
10-08 |
Drs. Statement |
DOC |
PDF |
ES-4310* |
10-08 |
Medical Documentation - Need for Care |
DOC |
PDF |
|
ES-4311* |
10-99 |
Declaration of Cooperation and Self-Responsibility Plan |
|
PDF |
|
ES-4313* |
01-05 |
Statement of Understanding for Vehicle Purchase |
DOC |
PDF |
|
ES-4314* |
01-07 |
Supervisor Checklist for Vehicle Purchase |
DOC |
PDF |
|
ES-4316* |
05-03 |
Screening/Referral Form |
DOC |
PDF |
|
ES-4320* |
01-09 |
Turn-Around Form - SRS Referral for OARS |
DOC |
PDF |
|
ES-4321* |
01-06 |
Obsolete |
ES-4322* |
|
Community Service/Work Experience Assignment and Site Report |
DOC |
PDF |
ES-4322.1* |
|
SRCC Community Service/Work Experience Assignment and Site Report |
DOC |
PDF |
ES-4411* |
10-07 |
Claim for Comparable Coverage |
DOC |
PDF |
ES-4412* |
12-07 |
Turn-Around Form Solutions Recovery Care Coordination (SRCC) |
DOC |
PDF |
ES-4413* |
12-07 |
Solutions Recovery Care Coordination (SRCC)
Assessment Results and Referral Form |
DOC |
PDF |
ES-4414* |
12-07 |
EES Case Worker Referral Form to Solutions Recovery Care Coordination (SRCC) |
DOC |
PDF |
ES-5000-E |
|
CASAS-ECS Appraisal Answer Sheets - English
(Reading/Math) (Available from SRS Warehouse) |
|
|
ES-5000-S |
|
CASAS-ECS Spanish - Reading Comprehension
Answer Sheets (Available from SRS Warehouse) |
|
|
ES-5001-E |
|
CASAS-ECS Appraisal Test Booklet - English
(Reading/Math) (Available from SRS Warehouse) |
|
|
ES-5001-S |
|
CASAS-ECA Spanish - Reading Comprehension
Test Booklet (Available from SRS Warehouse) |
|
|
ES-5002 |
|
CASAS-ECS Self-Addressed Return Envelopes
(Available from SRS Warehouse) |
|
|
ES-6000 |
|
Grandparents as Caregivers Resource Guide
|
|
PDF |
ES-6001 |
|
OBSOLETE |
|
|
ES-6001a |
|
OBSOLETE |
|
|
ES-6010 |
05-08 |
Becoming An SRS Child Care Provider Brochure |
|
PDF |
ES-6076 |
|
Partnering for Success Brochure |
|
PDF |
IS-3122* |
10-06 |
Disability Consultations/Representation Referral
to Kansas Legal Services |
DOC |
PDF |
|
IS-4308* |
01-05
|
Assessment Referral/Report |
DOC |
PDF |
|
IS-4315* |
05-04
|
EES & RS Referral/Communication Form |
|
PDF |
|