Model Welfare Guidelines Forms

These forms are offered as tools or guides to administer local assistance programs. Use of these forms is recommended but not mandatory.  When you click on the links below, the applicable form will download to your computer, not open in a web browser. 

Form A - Application for Assistance (DOCX, 51.84 KB)

Form B - DHHS Authorization to Release Information (PDF, 20.37 KB)

Form C - Notice of Rights of Anyone Receiving Assistance (DOCX, 13.41 KB)

Form D - Applicants Authorization to Furnish Information (DOC, 23.5 KB)

Form E - Applicant's Authorization to Furnish Information (Specific Agency/individual) (DOC, 23 KB)

Form F - Required Verifications (DOCX, 14.34 KB)

Form G - Welfare Intake (DOCX, 51.49 KB)

Form H - Municipal Welfare Dept Medical Release and Report (DOCX, 15.4 KB)

Form I - Employment Verification Form (DOCX, 14.17 KB)

Form J - Rental Verification Form (DOCX, 14.54 KB)

Form K - Budget Worksheet (DOCX, 14.1 KB)

Form L - Notice of Decision (DOCX, 13.93 KB)

Form M - Workfare Program Reporting Form (DOCX, 14.33 KB)

Form N - Employment Search Record (DOCX, 15.96 KB)

Form O - Fair Hearing Request (DOCX, 13.8 KB)

Form P - Notice of Fair Hearing (DOCX, 15.65 KB)

Form Q - Fair Hearing Decision (DOCX, 13.46 KB)

Form R - Notice of Property Lien (DOCX, 13.87 KB)

Form S - Notice of Property Lien Discharge (DOCX, 14.14 KB)

Form T - Rent Voucher - Landlord Delinquency (DOCX, 13.56 KB)

Form U - Update Application Form (DOCX, 13.68 KB)

Form V - Basic Needs Policy (DOCX, 13.88 KB)