Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DC0-1

Notice of Action

02/05

§         Manual notification of application approval when automated notice is not appropriate.

§         Request for information.

§         For TEA, notice that benefits will be held.

§         Advance notice of adverse action.

§         Manual notification of closure or change in benefits when an automated notice is not appropriate.

DHS GOLD

Spanish form on GOLD

Order from the warehouse.

Yes

DHS-10

Complaint Report

01/96

Used by DHS workers to register client complaints and to begin the process of resolving the complaint.

DHS GOLD

Order from the warehouse

No

DCO-12

Verification of Social Security Enumeration

06/99

§         Serves as verification of application for an SSN.

§         Notifies SSA of the application for an SSN.

§         Used by SSA to notify DHS of the status of the application for an SSN.

Order from the warehouse.

NA

DCO-19

Food Stamp Disqualified Recipient Report

08/04

§         Used by county office to report food stamp disqualifications to the central office, Food Stamp Section.

§         Used by central office, Food Stamp Section to enter information to the national Disqualified Recipient Information System. 

DHS GOLD

Yes

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-29

Quality Control Error Response

08/96

Used by the county office to provide information to the central office about any QA error case discovered.

DHS GOLD

Order from warehouse

Yes

DCO-70

Check Verification

08/85

Used by the county office to verify checks received by household. 

DHS GOLD ONLY

No

DCO-74

Request for Services in Alternate County

10/97

Completed by food stamp households to request service through a DHS county office other than the office in the household’s county of residence.  

DHS GOLD ONLY

No

DCO-76

Collateral Statement

09/97

Used to obtain verification of household composition and/or residence in questionable situations.

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DHS-80

Claim of Lost, Stolen and/or Forged Assistance Warrant/Check

07/97

Completed when a client reports a lost or stolen TEA or reimbursement check - e.g., E&T reimbursement check.

DHS GOLD ONLY

Yes

DCO-94

Second Party Review Summary

06/97

Completed by reviewer during second party review.

If needed, completed by worker to document corrective action.

DHS GOLD ONLY

Yes

DCO-97

Verification of Earnings

02/91

Used to obtain verification of earnings from the employer.

DHS GOLD

Order from warehouse

Yes

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-103

Request for Information at Midpoint Review

09/04

Used to obtain information and/or verification from a household that has submitted a Mid-point Review.

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-110

Complaint Report

01/02

Used by DHS clients to make a complaint. 

§         Records both civil rights complaints and other types of complaints.

§         Establishes a system for tracking complaints.

DHS GOLD ONLY

No

DCO-128

Categorical Eligibility Test

08/00

Used to determine if households are categorically eligible.

DHS GOLD ONLY

Yes

DHS-187

Billing and Routing Sheet/

Transitional Employment Assistance Payments/

Billed to the Department of Human Services

03/99

Used to authorize reimbursements for Food Stamp E&T Program participants

DHS GOLD ONLY

Yes

DCO-191

Request for Information -

Medicaid, Food Stamp and TEA Programs

07/05

Used to request information when a client has applied for benefits.  Used to request information postponed verification from expedited households.

DHS GOLD ONLY

Spanish form on GOLD

Order from the warehouse.

Yes

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DHS-199

Benefit Overpayment Report

10/98

Used to report food stamp overpayments to the Overpayments Unit.

DHS GOLD

Order from warehouse

Yes

DCO-201

Report of Restored Benefits

01/95

§         Used to document supervisory approval of restored benefits.

§         Used to report restored benefits to the Overpayments Unit.

DHS GOLD ONLY

No

DCO-205

Employment and Training Program

Referral Form & Participation Record

06/05

§         Used to refer both mandatory referrals and volunteers to the E&T contractor.

§         Used by the contractor as a participation record.

DHS GOLD ONLY

Yes

DCO-206

Food Stamp Program

Notice of Delayed Application

Form deleted.  No longer in use.

DCO-207

Food Stamp Workers Referral/Change

06/95

Used to refer food stamp recipients to the Workfare Sponsor in counties where the Workfare Program is operating.

Also used to transmit information that will affect Workfare participation.

Request forms from Office of Program Planning and Development, Food Stamp Section.

NA

DCO-208

Notification of Workfare Obligation

06/95

Used by the county office to notify Workfare Program participants of their Workfare obligation.

Request forms from Office of Program Planning and Development, Food Stamp Section.

NA

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-209

Workfare Exchange of Information

10/95

Used by the county office and the Workfare office to exchange information about workfare participants.

Request forms from Office of Program Planning and Development, Food Stamp Section.

NA

DCO-212

Workfare Monthly Activity Report

06/95

Used by the Workfare Administrator or designee to report program activity to the county office.

Request forms from Office of Program Planning and Development, Food Stamp Section.

NA

DCO-215

Request for Assistance

01/03

Multi-program application form

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-216

Statement of Responsibility

01/03

Attachment to the DCO-215: Client must sign to acknowledge that the penalties for false information have been explained to him or her.

DHS GOLD

Spanish form on GOLD

Order from warehouse

No

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-218

Request for Information

Semi-Annual Report

10/03

Request needed information from households who submit a semi-annual report

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-219

Notice of Appointment

08/04

Used to schedule appointments for TEA, Food Stamp and Medicaid applicants.

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-223

Application for Homeless Meal Provider Status

07/97

Used by homeless shelters that wish to accept voluntary contributions of food stamp benefits in exchange for meals.

DHS GOLD ONLY

No

DCO-224

Meal Provider Visit Record and Disposal

07/97

Used by the county to approve or deny homeless meal provider status.

DHS GOLD ONLY

No

DCO-231

Notice to Food Stamp Recipients

05/94

Used in counties where no interview is scheduled at recertification until the household submits an application.  Notifies households of the steps they must take to continue receiving food stamp benefits without interruption.

DHS GOLD

Spanish form on GOLD

No

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-234

Change Report

12/03

Used by food stamp, TEA and Medicaid households to report changes.

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-234A

Change Report Addendum

10/04

Explains the limited reporting requirements to food stamp households that are subject to this requirement.

DHS GOLD

Spanish form on GOLD

Order from warehouse

No

DCO-235

Instructions for Completing Midpoint Review Form

09/04

Accompanies the Midpoint Review Form sent to households with 24-month certification periods.  Explains the process and deadlines for reporting.

DHS GOLD

Spanish form on GOLD

Order from warehouse

Yes

DCO-238

Declaration of Food Loss

07/03

Used by households to request a full or partial replacement of food lost in household misfortune.

DHS GOLD ONLY

No

DCO-239

Notice of Food Stamp Certification Expiration

06/95

Advises food stamp households of the end of their certification period.  Schedules appointments for recertification.

DHS GOLD

Spanish form on GOLD

Computer generated form

Yes

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-243

Travel Reimbursement Documentation

10/04

Documents transportation costs incurred by E&T recipients.

DHS GOLD ONLY

No

DCO-244

Food Stamp Midpoint Review

11/01

Used to conduct a paper review of a household's circumstances in the 12th month of a 24-month certification period.

DHS GOLD

Spanish form on GOLD

Computer generated form

No

DCO-248

Food Stamp Adjustment - Automated 248 System

07/01

Used by workers to authorize a transaction (supplement, restoration, etc.) on daily issuance.

DHS GOLD

Order from warehouse

Yes

DCO-254

Daily Census Report

06/97

Used by treatment center to maintain a daily census of drug and alcohol treatment residents who receive food stamp benefits.

DHS GOLD ONLY

No

DCO-256

Action Taken on Administrative Disqualification Hearing or Waiver

05/03

Used by worker to notify a household that a member has been disqualified due to an IPV determined through a disqualification hearing or because the household waived their rights to a hearing

DHS GOLD ONLY

Spanish form on GOLD

No

DCO-259

Action Taken on Your Court Hearing

05/03

Used by worker to notify a household that a member has been disqualified due to an IPV determined through a court of law.

DHS GOLD ONLY

Spanish form on GOLD

No

Form Number

Form Name

Revision Date

Use

How to Access Form

Form Fields

DCO-260

Notification of Work Registration

06/05

§         Used in all counties to notify households when a member is work registered. 

§         Used in E&T counties to notify households when a member is referred to the E&T Program. Used in E&T counties to advise work registrants that they may volunteer to participate in the E&T Program.

DHS GOLD

Order from warehouse

No

DCO-263

Alcoholism and Drug Addiction Treatment Centers

Record of On-Site Visit

11/00

Used by the DHS county office to record on-site visits to treatment centers.

DHS GOLD ONLY

No

DCO-264

Alcoholism and/or Drug Addiction Treatment Center Declaration Form

03/02

An addendum to the Request for Assistance, this form is used by treatment centers to capture the information needed by the AR to complete an ANSWER interview.

DHS GOLD ONLY

No

DCO-271

Telephone Report

07/05

Used by workers to collect information from households that call the DHS county office to report a change in circumstances.

DHS GOLD

Order from warehouse

Yes