WAG 25-09-00: Form Retention List

FORM RETENTION LIST
Form Title of Form Section Time Frame
8 Real Property Record 3 Permanent
26 Report on Resident of Private Long Term Care Facility 4 Permanent
29 Funeral or Burial Claim 4 3 Years
34 Consent to Release Information 3 1 Year
34KC Consent to Release Information/KidCare 4 1 Year
43 Report Form 7 3 Years
43CF Report Form (centrally generated) 7 3 Years
44 Report on Personal Injury 5 Permanent
46 Bank Inquiry 3 3 Years
48 Estate Claim Card 5 Permanent
51 Assistance to the Blind - Report of Eye Exam 4 6 Years
65 Request to Withdraw Appeal 8 3 Years
65KC Request to Withdraw Appeal/KidCare 8 3 Years
79 Affidavit of Forgery - Completed by Payee 5 3 Years
85 Notice of Case Transfer 8 1 Year
94 Funeral and Burial Reimbursement Claim 4 3 Years
97 Verification of Birth, Marriage, Divorce, or Death 3 Permanent
98 Stop Payment and Recovery Agreement 5 3 Years (Unless part of an Overpayment Packet - Permanent)
102 Statement of Facts 8 3 Years
102KC Statement of Facts/KidCare 8 3 Years
103 Notice of Appeal 8 3 Years
103KC Notice of Appeal/KidCare 8 3 Years
110 Report on Charge for Injury Claim 5 3 Years
126 Recommendation Regarding Retention of Income Producing Property 3 Permanent
139 Inter-Office Memo Destroy After Action Taken
143 Questionnaire for Out of State Recipient 6 1 Year
146 Request for Therapeutic Diet Allowance 4 Keep Latest Copy
157 Notice of Change 8 3 Years
157DP1 Notice of Termination of Medical Enrollment/Assistance 8 3 Years
157ECF Notice of Termination of Medical Assistance 8 3 Years
157F Notice of Change - SNAPE&T Sanction 8 3 Years
157IA Notice of Change - Cat. P3 Medical Assistance 8 3 Years
157KC Notice of Change/KidCare 8 3 Years
157NC Notice of Change 8 3 Years
157P Notice of Change - Sanction 8 3 Years
157PCS Notice of Change - Sanction 8 3 Years
158 Request for Ledger Information 5 3 Years
167 Notice of Recoupment of Replaced Warrant 5 1 Year
183A Medical Evaluation - Physician's Report 4 6 Years
183B Medical Evaluation - Social Information 4 6 Years
183C Medical Evaluation - CAU Decision 4 6 Years
183D Medical Determination 4 6 Years
183E Client Authorization Form 4 6 Years
183F Client Assessment Unit Memorandum 4 6 Years
183GA Part IV - Client Authorization Form 4 6 Years
184B Evaluation of Need for Care 4 Keep Latest Copy
187 Asset Report for Deceased AABD MAG/MANG Client 4 Permanent
191 Small Business Schedule 7 Permanent
192 Estate Claim Transmittal 4 Permanent
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FORM RETENTION LIST
 Form Title of Form Section Time Frame
210 Farm Work Sheet 7 3 Years
213 Railroad Retirement Benefit Information 7 Permanent
222 Substitute Parental/Supplemental Child Care Statement of Services Rendered 1 1 Year
233 Certification of Release of Lien 3 Permanent
237 Notice and Claim of Lien 3 Permanent
243 Request for Assistance for Additional Family Member 1 Permanent
243A Request for Assistance for Additional Family Member 1 Permanent
243E Request to Add Adult Family Members to All Kids 1 Permanent
243KC Request for Assistance of Additional Family Member/ All Kids 1 Permanent
243KCA Request for Prior Coverage 1 Permanent
243KCB Request for Prior Coverage Notice of Denial 1 Permanent
256 Disbursing Order Authorization 8 3 Years
263 Quality Control Findings/FCRC Action 8 3 Years
263N Quality Control Findings/FCRC Action - Negative Case Action Sample 8 3 Years
266/1442 Request for Employment Verification/Health Insurance Report 5/7 Permanent
266A/1442 Request for Employment Verification - AABD/Health Insurance Report 5/7 Permanent
266ACF/1442 Request for Employment Verification (AIS)/Health Insurance Report 5/7 Permanent
266B Request for Employment Verification 5/7 Permanent
266CF Request for Employment Verification 5/7 Permanent
266KC Request for Employment Verification/KidCare 5/7 Permanent
266TPL/1442 Request for Health Insurance Verification 4 Permanent
267 Instructions to Client 6 1 Year
267D Instructions to Client (Supplement) 6 1 Year
267E Request for Additional Information (All Kids) 6 1 Year
267F Instructions to Client/KidCare 6 1 Year
267KC Instructions to Applicant/KidCare 6 1 Year
267L Notice of Missed Interview 6 1 Year
267M Instructions to Client (QMB) 6 1 Year
267TPL Medical Insurance Inquiry 4 1 Year
280 Notice of Change (to Mental Health) 8 Keep Latest Copy
305 Mailing Request/Disposition Action 4 3 Years
308 Release of Medical Information 4 6 Years
322A Administrative Control 4 Destroy After Antic. Change
330 Evaluation of Homes Not Subject to Licensing 4 Keep Latest Copy
337 Receipt for Certificate of Title 3 Permanent
357 Notice of Benefit Change Resulting from a Report Form 7 3 Years
357A Notice of Benefit Change 7 3 Years
360 Notice of Decision on Application 1 3 Years
360A Action Taken on Your SNAP Case/Notice of Expiration of Certification Period 2 3 Years
360B Supplement to Notice of Decision on Application-AABD 1 3 Years
360C Notice of Decision on Application 1 3 Years
360D Notice of Decision on Application 1 3 Years
360E Notice of Decision on Application 1 3 Years
360F Notice of Decision on Application 1 3 Years
360G Notice of Decision on Application 1 3 Years
360H Notice of Decision on Application 1 3 Years
360I Notice of Decision on Application 1 3 Years
360J Notice of Decision on Application 1 3 Years
360K Notice of Decision on Application 1 3 Years
360KC Notice of Decision on Application/KidCare 1 3 Years
360M Notice of Decision on Application 1 3 Years
360N Notice of Decision on Application 1 3 Years
360P7 Notice of Decision on Application 1 3 Years
360P8 Ineligible Persons 2 3 Years
360Q Notice of Decision on Application 1 3 Years
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FORM RETENTION LIST
Form Title of Form Section Time Frame
430 Application for Volunteer Service 6A 1 Year
458 Notice of Decision on Application for Medical Assist. 1 3 Years
458D Notice of Decision of Limited Approval on Application for Medical Assistance - Non Spenddown 1 3 Years
458LTC Notice of Decision - MANG Long Term Care 1 3 Years
458M Notice of Decision for Payment of Medicare Premiums 1 3 Years
458SP Notice of Decision on Application (MANG) 1 3 Years
458SP-1 Notice of Determination of Monthly Spenddown Met/Unmet 1 1 Year
458SP-3 Notice of Determination of SPD Met/Unmet - LTC 1 1 Year
458SPA Supplement to Form HFS 458P/2434A - AABD 4 1 Year
458SPB Supplement to Form HFS 458SP/2434A - 94/96 4 1 Year
493 Change in Case/Custodial Parent Statute 4A Keep Latest Copy
514 Information on Case History 8 Permanent
514KC Information on Case History/KidCare 8 Permanent
541 Verification of School Attendance 3 Keep Latest Copy
541A School Attendance Initiative Referral 6A 1 Year
541CF Verification of School Attendance 3 Keep Latest Copy
552 Authorization of Assistance Action 9 4 Years
552B Form 552 Supplemental 9 1 Year
553 Budget Computation and Instruction Sheet 7 1 Year
553A Budget Computation Worksheet 7 1 Year
553GC Attachment to Computation of Grant/SNAP 7 3 Years
553H TANF/SNAP Computation - Work Pays 7 3 Years
553I Approval TANF/SNAP Computation 7 3 Years
553J Worksheet for Computation of TANF/SNAP - Work Pays 7 3 Years
632H Medical Report Regarding Applicant for Public Assistance 4 6 Years
639 Notice of Returned Documents 8 1 Year
639KC Notice of Returned Documents 8 1 Year
643 Redetermination Report Form 6 Permanent
643D Attachment to Redetermination 6 Permanent
643E  Your Children's Medical Eligibility 6 Permanent
643E-1 Your Family's Medical Eligibility 6 Permanent
643F Request for SNAP 2 Permanent
643G AABD Redetermination Report Form 6 Permanent
643H Attachment to Form 643G 6 1 Year
643KC Redetermination Report Form/KidCare 6 Permanent
654 Instructions to Physician for Completing Part 1 of Form 183A 4 Destroy Upon Application Disposition
683 Application for SNAP 2 Permanent
683A SNAP Eligibility Worksheet 2 3 Years
683B SNAP Calculation Sheet 2 3 Years
683C Determination of Monthly Income from Annualized Self-Employment 7 3 Years
683L Voter Registration/SNAP Recertification 2 Keep Latest Copy
693 Return or Exchange of Unused Link Card 2 3 Years
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FORM RETENTION LIST
 Form Title of Form Section Time Frame
915 Report of Incapacity (Replaced by Form 2901) 4 6 Years
922 Life Insurance Review 3 Keep Latest Copy
1015C Notice of Appointment 6 1 Year
1044 Referral or Route Slip 6 Destroy after Action Taken
1067 Responsible Relative Master Record 4A Permanent
1095A Office of Ombudsperson Inquiry Summary 8 1 Year
1156 Long Term Care Facility Notification 4 Keep Latest Copy
1201 Appeal Control Card & Pre-Hearing Review Quality Checklist 8 Destroy 3 Years After Final Administrative Decision
1229 Redetermination - Group Care/Sheltered Care 6 Permanent
1229A Group Care Rede Report Form 6 Permanent
1253 Premail Action Request 4 3 Years
1260A Notice Concerning Good Cause for Refusal to Cooperate 4A Keep Latest Copy
1265 Salvation Army Emergency Lodge Referral and Authorization Form 6A 1 Year
1283 Application for Child Support Enforcement Services 4A Permanent
1301 Request to Veterans Administration 7 3 Years
1303 Notice of Attempted Home Visit 6 1 Year
1313D Medical Eligibility Change/Correction 4 1 Year
1373 Receipt for Returned Check 4 1 Year
1376 Summary of Case Information 3 Keep Latest Copy
1376A Caseworker's Control Card for PE Cases 3 Destroy after Case Certified
1377 Verification of Need for Medical Transportation 4 Keep Latest Copy
1377A Medical Transportation Need Letter 4 Keep Latest Copy
1381 Request for Action on Group Care Admission 4 Keep Latest Copy
1398 Warrant Operations Recipient History Card 5 Permanent
1403 Signature Exemplar Document Examination 5 3 Years
1404 Check Receipt 4 1 Year
1411C Request for Temporary Medical Card 4 Destroy after Exp. Date
1442 Health Insurance Resource Report 4 6 Years
1442/266A Health Insurance Report/Request for Employment Verification - AABD 4 6 Years
1456 Implementation of Appeal Decision 8 3 Years
1456KC Implementation of Appeal Decision/KidCare 8 3 Years
1547B Volunteer Protective Payee Ledger 8 1 Year
1548A Recipient Ledger 8 1 Year
1552 Determination of Disability - AABD(D) 4 6 Years
1611 Notice of Failure to Cooperate with Child Support 4A 1 Year
1611A Notice Regarding Client Cooperation in the Court Process 4A 1 Year
1611B Notice of Failure to Cooperate in IV-D Interview 4A 1 Year
1619 Funeral and Burial Claim Report 4 1 Year
1645 Transmittal Memo - Transfer of Case Records 4 Destroy After Transfer-In
1653 Request for Protective Payee 8 Destroy 1 Year After PPP Ends
1661 Notice of Receipt of Child Support 7 Keep Latest Copy
1662 Primary Care Provider Authorization 4 6 Years
1693 Appeal/Pre-Appeal Implementation Request 8 3 Years
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FORM RETENTION LIST
Form Title of Form Section Time Frame
1709 Request for Excess Shelter Allowance 1 Keep Latest Copy
1721 Instructions to Client - Redetermination of Eligibility 6 1 Year
1721A Instructions to Client - New Hire 6 1 Year
1721B Instructions to Client - Special Review 6 1 Year
1721C Instructions to Client - Earnings Information 6 1 Year
1721E Instructions to Client/KidCare 6 1 Year
1721GC Instructions to Client - LTC Facilities 6 1 Year
1721 ACM Instructions to Client - Redetermination of Eligibility 6 1 Year
1760 Report on Child Support Terms 4A 1 Year
1766 Notice of Failure to Report Child Support 4A 1 Year
1786 Title Search Sheet 3 Permanent
1803 Case Record Transfer Transmittal 8 1 Year
1864 Referral For Medical Examination 4 1 Year
1868CFS Notice of Foster Care Placement 3 1 Year
1889 Student Financial Aid Inquiry 7 3 Years
1897 Statement of Child Care Costs 7 1 Year
1897A Statement Of Child Care Costs Due to Employment 7 1 Year
1901 Report of Client Non-Cooperation with Support Enforcement Due to a Claim of Good Cause 4A 1 Year
1925 Discrepancy Referral Form 7 1 Year
1925KC Discrepancy Referral/KidCare 7 1 Year
1932 Substitute Parental/Child Care Request 1 1 Year
1934 Notice Of Decision On Request For Cash Assistance 1 1 Year
1934A Notice of Decision to Add Person to Medical Case 4 1 Year
1952 Notice Of Extension Of Time Limit For Disposition Of Application 1 1 Year
1958 Burial Claim Transmittal 4 1 Year
1959 Funeral/Burial Payment Request Notice 4 1 Year
1977 Acknowledgment of Receipt of Hysterectomy Info. 4 6 Years
1978 SNAP Program Change Report Form 2 3 Years
1979 Your SNAP Is Expiring 2 3 Years
1988 SNAP Program Response To Reported Change 2 3 Years
1989 Request For Replacement of Destroyed Food Or LINK Card 2 3 Years
1992 Request To Apply Past Month SNAP Benefits to Unpaid Claim Balance 2 3 Years
2020 Utility Payment Plan 8 3 Years
2027RA Redetermine Refugee Assistance 6 Permanent
2122 Notice Of Anticipated Change 4 Destroy After Change
2149 Request For Name Change 3 3 Years
2150 Request For Specific Case Guidance 8 3 Years
2151 Referral Form 6A 1 Year
2151A Change/Progress Report 6A 1 Year
2151D Teen Parent Services Change/Progress Report 6A 1 Year
2192 Intake Referral 1 Destroy After Action Taken
2201 Earned Income Verification 7 Permanent
2221 Notice of Move 4 1 Year
2221NM Notice of Non-Payment of Care due to Change in Level of Care 4 1 Year
2222 Notice of Denial of Continued Payment 4 1 Year
2223 Physician's Certificate 4 1 Year
2239 Transportation Prior Approval Request 4 1 Year
2255 PPP Fund Account Bank Reconciliation 8 1 Year
2271/2271A Earned Income Referral Form Desk File/7 3 Years
2281 Change in the Amount Owed for Group Care (replaced by Form 2500) 7 Keep Latest Copy
2289 SSA Verification Memo 3 1 Year
2299 Long Term Care Authorization 4 Keep Latest Copy
2299D Long Term Care Authorization (replaced by 2299) 4 Keep Latest Copy
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FORM RETENTION LIST
Form Title of Form Section Time Frame
2304 Verification of Pregnancy 4 1 Year (or until birth)
2304KC Verification of Pregnancy/KidCare 4 1 Year (or until birth)
2329 SNAP Employment & Training Job Search Notice & Report 6A 1 Year
2329J TANF Work and Training Job Search Notice and Report 6A 1 Year
2350 Notice of Possible Entitlement to Temporary Medical Assistance 1 1 Year
2352 Notice of Decision on Request for Medical Service/Item 4 1 Year
2354 Status Report/Late Application Disposition 1 1 Year
2355 Non IV-D Support Referral 4A 1 Year
2366 Authorization Of Payment Of Transportation Expense 4 1 Year
2372/2372CF Interstate Duplicate Assistance Worksheet 5 3 Years
2378B Request for Cash Assistance, Medical Assistance, SNAP 1 Permanent
2378C Request For Cash Assistance-Medical Assistance-SNAP 1 Permanent
2378E Cover Sheet for HFS 2378MC for Inmate/Parolee of Correctional Facility 1 1 Year
2378H Request for Medical Assistance 1 Permanent
2378KC All Kids Application 1 Permanent
2378KCA Agreement Form/KidCare 1 Permanent
2378KCB Rebate Form 1 Permanent
2378M Application for Payment of Medical Premium 1 Permanent
2378MC State of Illinois - All Kids Application 1 Permanent
2378TA All Kids Telephone Application 1 Permanent
2380 Notice of Denial of Request for Compensatory Payment 1 Permanent
2382 AABD Cash Computation Sheet 1/6 1 Year
2382A AABD MANG Computation Sheet - Community Case 1/6 1 Year
2382GC AABD MANG Computation Sheet 1/6 1 Year
2382M QMB or SLIB Computation Sheet 1/6 1 Year
2383 TANF Cash Computation Form 1/6 1 Year
2383A Parent Assist/Moms and Babies Computation Sheet 1/6 1 Year
2383B Supplement to Form 2383 1/6 1 Year
2383C TANF MAG Computation Form 1/6 1 Year
2386 Short Form Intake Application for Recertification - SNAP (Supplement to Form 2378) 2 Permanent
2388 Eligibility Summary/Disposition 1 1 Year
2391/2391A Protective Payment Plan Agreement 8 1 Year After PPP Ends
2392 Notice To Client Of Protective Payment Plan 8 1 Year After PPP Ends
2393 Notice To Client Of Creditor Request - TANF 8 1 Year After PPP Ends
2397 Notice to Person Appealing 8 1 Year
2397A Notice to Persons Appealing a Determination of "Is Not Probably Eligible for SSI" 8 1 Year
2400 Report Of Action Form 2 3 Years
2404 Overpayment Referral 5 Permanent
2404 ACM Overpayment Referral Part I 5 Permanent
2404C Change Of Overpayment Information 5 Permanent
2404X Notice Of Overpayment 5 Permanent
2404XA Client Rights 5 Permanent
2404XAF Notice Of Overpayment SNAP 5 Permanent
2404XAG Notice Of Overpayment Grant 5 Permanent
2418 Notice to Recipients of Refugee Assistance 8 1 Year
2418A Notice to Recipients of Refugee Assistance (Outside the City of Chicago) 8 1 Year
2422 Verification Of Contribution From Volunteer Sponsoring Agency 7 3 Years
2424 Referral To Refugee Job Placement Agency 6A 1 Year
2430ASP Summary of Medical Expenses/Spenddown 4 1 Year
2431 Application of Medical Assistance - Short Form 1 Permanent
2432 Split Billing Transmittal for MANG Spenddown Program 4 1 Year
2434 Enrollment Status Information or Changes During the Established Period 4 1 Year
2434A Notice of Changes During the All Kids Enrollment Period or Eligibility Period 4 1 Year
2434C Notice of Change - MANG Long Term Care Case 4 1 Year
2434D Notice of Change During the Enrollment Period for Pregnant Women and for Children 4 1 Year
2434E Notice of Change Regarding Eligibility for Medical Assistance 4 1 Year
2434EPr Notice of Change to All Kids Premium 4 1 Year
2434ERe Notice of Change to All Kids Rebate 4 1 Year
2434ESh Notice of Change to All Kids Share 4 1 Year
2448 Physician Certification 4 Keep Latest Copy
2449 Long Term Care Update 7 Keep Latest Copy
2466A FSE&T Monthly Attendance and Progress Report 6A 1 Year
2467 Shelter Arrangement - Change of Address Worksheet 2 Keep Latest Copy
2468 Authorization of Assistance - PE 1 1 Year
2476 Notice of Disqualification of Authorized Representative 2 3 Years
2484 Notice Regarding Trust Fund 3 Permanent
2491 Pre-Appeal Appointment Conference Letter 8 1 Year
2491KC Pre-Appeal Appointment Conference Letter/KidCare 8 1 Year
2493 Authorization for Deposit of Public Assistance Warrant 8 1 Year
2493A Authorization for Deposit/Protective Payee 8 1 Year
2496 Direct Deposit System - Disenrollment Request 8 1 Year
2498 Agreement Regarding Sale/Transfer Of Real Property 3 Destroy After Sale of Property
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FORM RETENTION LIST
Form Title of Form Section Time Frame
2500 Group Care Resource Calculation 7 Keep Latest Copy
2503G SNAP Employment & Training (SNAPE&T) Participation Review Notice 6A 1 Year
2509 Notice to P3 Transitional Assistance Client 1 1 Year
2509A Notice to P3 Medical Assistance Client 1 1 Year
2518 Bureau of Special Investigations Investigation Report 5 Permanent
2518A Investigation Report 5 Permanent
2518B Investigative Summary 5 Permanent
2536 Interagency Certification of Screening Results 4 Keep Latest Copy
2537 Notice of Denial of Payment for SLF, SNF, ICF, or ICF/MR Services 1 3 Years
2538 Interagency Request for Income/Assets Information for In-Home Care Applicant or Recipient 4 Return to Requestor (do not keep copy)
2538B Illinois Department on Aging Notification 4 1 Year
2539 Notice of Second Opinion Decision on Request for SLF, SNF, ICF, or ICF/MR Services 1 1 Year
2540 Verification of Living With 3 Permanent
2543 SNAP Program Request for Replacement of Partial Allotment 2 1 Year
2548 Notice of Suspected Intentional Program Violation 5 Destroy After Disqualif. Period
2549 Waiver of Right to an Administrative Disqualification Hearing E/S 5 Destroy After Disqualif. Period
2550 Notice Of Disqualification For Initial Program Violation 5 Destroy After Disqualif. Period
2550A Inter-Office Memorandum from Bureau of Collections 5 3 Years
2551 Demand Letter Intentional Program Violation 5 Destroy After O/P Ends
2551A/2551AS Repayment Agreement - Intentional Program Violation 5 Destroy After IPV Ends
2555B Demand Letter - Inadvertent Household Error 5 Destroy After O/P Paid
2555BC Demand Letter - Inadvertent Household Error 5 Destroy After O/P Paid
2556 Demand Letter - Administrative Error 5 Destroy After O/P Paid
2556CH Demand Letter - Administrative Error 5 Destroy After O/P Paid
2557 Demand Letter - Grant Overpayment 5 Destroy After O/P Paid
2575A HMO Enrollment Application 4 Keep Latest Copy
2575B Managed Care Entity Disenrollment Form 4 1 Year
2606 Monthly Activity Report 6A 1 Year
2606D Monthly Earnfare Referral and Attendance Record 6A 1 Year
2606E Work First Referral and Attendance Record 6A 1 Year
2617 SNAP Program - Request For Replacement Of LINK Card 2 3 Years
2622 Client Grievance Form 8 3 Years
2633 Notice Of Administrative Review Of Application 1 Permanent
2636 Record Of Birth 3 Permanent
2646 SNAP Work Registration Notice 2 3 Years
2653 Notice of DHS Community Based Services 1 Keep Latest Copy
2656 Notice Re: Receipt of Child Support Pass Through Payment 7 1 Year
2666 Statement Of Ownership Of Joint Assets 3 Permanent
2674 Payment For Psychological/Psychiatric Testing 4 1 Year
2689 Request For Crisis Assistance 1 3 Years
2690 Notice Of Decision On Request For Crisis Assistance 1 3 Years
2691 Filing Unit Notice 3 1 Year
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FORM RETENTION LIST
Form Title of Form Section Time Frame
2744 Notice of Decision on Request for Pharmaceutical Service/Item 4 6 Months
2755 Investigation Referral 5 3 Years
deleted text
2790 Self-Employment Record 7 Permanent
2790KC Self-Employment Record 7 Permanent
2805GA SNAPE&T Success Story and Consent Form 6A 1 Year
2807 Notice About Change In Benefit Availability Date 7 1 Year
2826 Request For Status Review 6A 3 Years
2826GA Request/Disposition SNAP Employment & Training Exemption - TA and SNAP 6A 3 Years
2827 Notice Of Decision On Status 6A 3 Years
2839
SNAPE&T Assessment/Employability Plan		 6A 3 Years
2840D SNAPE&T Earnfare Participation Requirements 6A 3 Years
2840E SNAPE&T Vocational Training Participation Requirement 6A 3 Years
2840G SNAPE&T Job Search Participation Requirements 6A 3 Years
2846 Reconciliation Appointment Notice 6A 3 Years
2846A Reconciliation Agreement 6A 1 Year
2846G SNAPE&T Conciliation Appointment Notice 6A 3 Years
2849 Verification Checklist for Resident of DHS Facility 1 Permanent
2855 Request for Employment Expenses 6A 3 Years
2858D SNAPE&T Notice of Determination of Eligibility for Earnfare 6A 3 Years
2858E SNAPE&T Notice of Termination from Earnfare Participation 6A 3 Years
2864 Authorization to Request Earmarked Child Support 4A Permanent
2878 Notice Of Withdrawn Appeal 8 3 Years
2880 Deferred Asset Agreement - AABD 3 1 Year
2881 VA Outreach Report Sheet 7 Keep Latest Copy
2900 Notice of Denial of Medical Assistance Benefits (Replaced by 360D or 360H) 1 Permanent
2901 Documentation Of Medical Condition 4 6 Years
2905 Request For Financial Assistance 1 Permanent
2941A Notice of Appointment 6 1 Year
2943 Grant/SNAP Eligibility, Central Notice & Grant Computation Information 9 1 Year
2952 Pink Case Record Sign Out Card 9 Permanent
2956 Child Support Form 4A Permanent
2958 Request for Correction/Addition to MMIS Eligibility File 4 1 Year
2998 Approved Representative Consent Form 1 Permanent
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FORM RETENTION LIST
Form Title of Form Section Time Frame
3021 Payment Transmittal Slip 5 1 Year
3024 Data Collection Document 7 Permanent
3027 Income Tax Match Affidavit for Forgery or Duress 3 Permanent
3028 Income Tax Match Spouse Affidavit 3 Permanent
3029 Income Tax Match/Affidavit for Unavailable Income 3 Permanent
3044 Orientation Appointment Notice 6A 1 Year
3067 Case Review Findings 6 Permanent
3076 Prior Approval Notification 4 1 Year
3089 Health Start Application (Medicaid Presumptive Eligibility) 1 Permanent
3090 Notice of Instructions to Pregnant Applicant 6 1 Year
3112 Notice of Child Support for a Zero Grant or Suspended Case 7 1 Year
3132 Notice Regarding Medicare Cost Sharing 1 1 Year
3148 Adjudication of Paternity 4A Permanent
3155 Consent of Disclosure 3 1 Year
3162 Declaration Regarding Citizenship/Alien Status 1 Permanent
3168 Requirement To Apply For A Social Security Number 3 2 Years
3180 Agreement to Meet Program Requirements 6A 1 Year
3184 Child Care Provider Certification Form 6A 1 Year
3185 Disposition Of Child Care Request 3 1 Year
3189 Request for Information (Assessment of Assets) 3 1 Year
3190 Assessment of Assets 3 Keep Latest Copy
3192 Determination of Asset Allowance 3 Keep Latest Copy
3195 TCAR System Review Form - Asset Report for Deceased Clients Destroy After Review
3218 Veterans Benefits 7 Keep Latest Verification
3288 SSA Consent for Release of Information 3/4/7 1 Year
3294 Deceased Responsible Relative/SSA Benefit Notice 7 1 Year
3354 TANF Work & Training Employment Services 6A 1 Year
3354A Work & Training Employment Services Follow-Up 6A 1 Year
3361 Request For Extension Of Medical Assistance 7 Permanent
3363 Notice of Benefit Restoration 8 3 Years
3392 SNAPE&T Conciliation Agreement 6A 3 Years
3392A SNAPE&T Non-Assistance SNAP Conciliation Agreement 6A 3 Years
3410 Confirmation of Appointment for Physical Examination 4 1 Year
3416B Voluntary Acknowledgment of Paternity 4A Permanent
3416D Denial of Paternity 4A Permanent
3416E Recission of Voluntary Acknowledgment of Paternity 4A Permanent
3419 Notification of Lien 5 Permanent
3438 When Cash Assistance will be Received 5 1 Year
3442 Reporting Changes 4 1 Year
3444 Office of Rehabilitation Services Letter of Notification 4 Keep Latest Copy
3452 Car Seat Loan Agreement 8 1 Year
3454 Notice of Payment 7 1 Year
3459A Health Insurance Premium Payment (HIPP) Inquiry 4 Keep Latest Copy
3459B Health Insurance Premium Payment (HIPP) Referral 4 1 Year
3462 Request for Proof of Housing 2 Keep Latest Copy. Also keep previous for 1 Year from date of previous address change
3489 Transfer of Assets Worksheet 3 Permanent
3500 Notice of Review of Eligibility for State Supplemental Payment (SSP) 6 1 Year
3602 Certification of Pregnancy and Expected Due Date 3 1 Year
3604 Minor Parent Live at Home Verification 3 Destroy After Parent is No Longer a Minor
3606 Representative Payee for Teen Agreement 8 Keep Until Agreement Ends
3617 Request For Supplemental Payment 1 3 Years
3619 Alleged Existence Father/Child 4A Permanent
3619A Statement Alleging the Existence of the Father and Child Relationship 4A Permanent
3625 Affidavit of Acknowledgment of Paternity 4A Permanent
3625A Affidavit of Acknowledgment of Paternity 4A Permanent
3626 Agreement to be Bound by the Results of Genetic Test 4A Permanent
3626A Agreement to be Bound by the Results of Genetic Test 4A Permanent
3646 Paternity Establishment Information 4A Permanent
3655 LINK Proxy Statement 8 Permanent
3657 Illinois Link Card Notice 8 1 Year
3658 Link Card/PIN Issuance Form 8 Keep with EBT documents
3658A Attachment I - Link Destroy
3660 Return of Illinois Link SNAP Benefits 2 3 Years
3662 Notice of Decision on Request for SNAP Benefit Conversion 2 3 Years
3663 Request to Reissue Illinois Link Benefits 8 1 Year
3664 Request to Convert Illinois Link Benefits to Paper Coupons 2 1 Year
3669 What's New Tell Us About It Card Destroy After Processing
3672 Participation in the Transitional Assistance Program (TAP) 4 1 Year
3673 Volunteer Community Work Information 4 Permanent
3680 Declaration of Employment 3 Permanent
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FORM RETENTION LIST
 Form Title of Form Section Time Frame
3703 Exempt Irrevocable Trust Referral 5 Permanent
3708 Notice Regarding Your Copays 4 3 Years
3708A All Kids Notice, Re: Your CoPay 4 1 Year
3718 Notice of Decision on Addition of a Child 1 1 Year
3718KC Notice of Decision on Addition of a Child - All Kids 1 1 Year
3719A All Kids Rebate Notice of Change 1 3 Years
3719KC All Kids Rebate - Notice of Approval 1 1 Year
3720 All Kids Report of Change 6 1 Year
3720KC Report of Change 6 1 Year
3721 Notice of Change in Premium and Copay Amounts 4 3 Years
3722A All Kids Share/Premium/Rebate Change Report Form 6 1 Year
3726 All Kids Copay Tracking Form 4 3 Years
3744 Family Community Resource Center Memo Transferring Case Destroy
3744A Letter to Applicant - Case at DHS Family Community Resource Center 4 1 Year
3744B Letter to Applicant - Case at Family Community Resource Center 180/220 4 1 Year
3754 All Kids Renewal Notice 6 1 Year
3754A All Kids Renewal Notice 6 1 Year
3754B All Kids Renewal Notice 6 1 Year
3754C All Kids Renewal Notice 6 1 Year
3754D All Kids Renewal Notice 6 1 Year
3754E All Kids Renewal Notice 6 1 Year
3754F All Kids Renewal Notice 6 1 Year
3754G All Kids Renewal Notice 6 1 Year
3754H All Kids Renewal Notice 6 1 Year
3754I All Kids Renewal Notice 6 1 Year
3754J All Kids Renewal Notice 6 1 Year
3759 Attestation of Information 4A Permanent
3762 Premium Debt Cancellation Letter 4 3 Years
3766 19 Year Old Aging Out 1 1 Year
3770 Rebate SWAP Letter 4 3 Years
3771A Reinstatement Letter 1 3 Years
3778 Request to Add a Person to a DHS Case 4 Permanent
3789 Additional Household Information Form 1 Permanent
3806K Authorization to Disclose Information 3 3 Years
3818 Notice of PE Approval 1 3 Years
3818A Notice of PE Denial 1 3 Years
4001 Family Assessment 6A Permanent
4001A Family Assessment - Employment, Education, and Training 6A Permanent
4001B Family Assessment - Family Health 6A Permanent
4001C Family Assessment - Treatment Screen 6A Permanent
4001D Treatment Indicators Checklist 6A Permanent
4001E Family Assessment - Elderly 6A Permanent
4002 TANF Eligibility Information 6A Permanent
4003 Responsibility and Services Plan - TANF Agreement 6A 1 Year
4003A Responsibility and Services Plan - Employment, Education, and Training Goal 6A 1 Year
4003B Responsibility and Services Plan - Family Issues Goal 6A 1 Year
4003C Responsibility and Services Plan - Treatment Goal 6A 1 Year
4004 Resource Connections Checklist 6A 1 Year
4012 Domestic Violence Screening & Referral Form - Options 6A 1 Year
4013 Intake Responsibility and Services Plan 6A 1 Year
4014 Notice of Child Care Copayment 4 Permanent
4016 Consent to Release Certain Confidential Information 1 1 Year
4017 Intake Mail-In 1 Permanent
4018 Self-Support Assessment 6A Permanent
4019 Participation in Community Work Program 6A 1 Year
4019A Certification of Work Program Participation 6A 1 Year
4020 Intake Assessment 6A 1 Year
4020A Checklist for Referral to Vocational Rehabilitation 6A 1 Year
4021 Case Disposition 6A 1 Year
4022 Notice to Child Care Resource and Referral Agency 6A 1 Year
4026 Client/Applicant Discrimination Complaint Form 4 Permanent
4028 Notice of Obligation to Support 4A 1 Year
4029 Acknowledgment and Declaration 4A Permanent
4030 Administrative Support Order 4A Permanent
4031 Redetermination of Obligation to Support 4A Permanent
4033 State SNAP Program Application 2 Permanent
4043 Work First Notice 6A 1 Year
4043A Work First Notice - Downstate 6A 1 Year
4044 Work Experience/Work First Work Sheet 6A 1 Year
4046 SNAPE&T Status Report Form 6A 3 Years
4048 Illinois Link Account Adjustment Request 8 3 Years
4050/
4050C		 AABD/SNAP Computation 6 3 Years
4072 TANF Work & Training Referral for Optical Services 6A 1 Year
4120 Verification Checklist for Released Inmate 1 Permanent
4121 Instructions to Applicant From DOC Facility 6 1 Year
4136 Collection Notice 4 1 Year
4169 Notice of Special Appointment 6 1 Year
4178 Notice of Cancellation For Child Care Payments 6A 1 Year
4179 Denial of Request For Child Care Payments 6A 1 Year
4232 Physician's Medical Review 4 6 Years
4238 QC Review Letter 8 3 Years
4253 Illinois WIC Program Certification Form 4 3 Years
4254 WIC Identification Card 4 3 Years
4256 Control Card - Request For Transfer to Nursing Home 4 1 Year
4257 Notification of CBO Enrollment/Authorization Completion 4 1 Year
4258 Child & Family Connections Transmittal 1 1 Year
4259
pp 1- 11		 Individualized Family Service Plan 6A Permanent
4265 Consent For Release 1 1 Year
4274 All Kids Expert Control Log 1 Permanent
4324 Certification of Pregnancy & Expected Due Date 4 1 Year
4325 Request for Dependent SSN 3 1 Year
4333 Work First List 6A 1 Year
4334 Work First Staffing 6A 1 Year
4335 Your TANF Time Limit 6A 1 Year
4336 Child Care & the TANF Work Requirement 4 1 Year
4363 Child Intake Addendum 1 1 Year
4419A-E Family Assessment 6A Permanent
4420A-E Responsibility and Services Plan 6A Permanent
4421 Treatment Indicators Checklist 6A Permanent
4450 Release and Consent Form 1 1 Year
4469 Child Care Rate Certification Form 4 Permanent
4647 Referral for Assessment 4 Permanent
4652 Intensive Review Guide 6 Permanent
4691 Request for Exception 3 Permanent
4692 Exception Request Summary 3 Permanent
4701H Authorization to Release Medical Records 4 1 Year
4728 Learning Needs Screening 6 Permanent
4765 Earned Income Redetermination Application 2 Permanent
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 FORM RETENTION LIST - MISCELLANEOUS
C-13  Invoice Voucher 4/6A 1 Year
C-13C Voucher 4/6A 1 Year
DOC 240  Authorization for Release of Offender Mental Health or Substance Abuse Treatment Information 4 1 Year
DOC 241 Authorization for Release of Offender Medical Health Information 4 1 Year
E26051.RS JTPA Referral Form 7 1 Year
FA13/FA13c Invoice Voucher - Disbursing Order 4/6A 1 Year
G-845 Document Verification Request 3 Permanent
PA-5 Notice of Returned Warrant 5 1 Year
PAS042882 Notice From Project Administration 5 1 Year
SRF-5 Supervisory Review - Case Findings Destroy
SS 5 Application for SSN Card 3 Destroy After # Verified
SSA 1610-V2 Public Assistance Agency Information Request 7 1 Year
SSA 2458 Report of Confidential Social Security Information - SSA 7 1 Year
SSA 4340 SNAP Quality Control Computation Sheet 2 3 Years
SSA 211802 Request For Documents or Information - SSA 3 1 Year
SSA-L-74 Social Security Administration SSA Referrals 7 2 Years
SSA-L8025 Supplemental Security Income - Notice of Award 7 1 Year
WPP 13604 TCAR SNAP Priority Review Don't File - Destroy After Review and/or Correction
Alien Status Verification 3 Permanent
Asset Report from OIG 3 Permanent
Appeals - Final Administrative Decision 8 3 Years
Attachment to HFS 29 4 3 Years
Bank Statements 3 Keep Latest Copy
Birth Certificate 3 Permanent
Car Registration/Car Title Information 3 Latest
Chicago Student Online Clearance Inquiry 3 Keep Latest Copy
Correspondence from or regarding client that does not pertain to eligibility 8 1 Year
Court Orders 3 Permanent
Crossmatch File Face Sheet 5 1 Year-Unless part of O/P packet
Death Certificate 3 Permanent
Divorce Certificate 3 Permanent
Emergency Assistance/Hardship Request Memorandum 1 Permanent
SNAP Signature Document 2 3 Years
Letter regarding restoration of SNAP benefits 2 3 Years
Letters requesting client response when response has been made 8 1 Year
Life Insurance Information 3 Keep Latest Copy
Marriage Certificate 3 Permanent
Medical Bills 4 Return to Client After Entering
Out of State Inquiries/Letters 8 1 Year
Rent Receipts/Utility Bills 2 Retain Current. Also keep previous for 1 Year from date of previous address change
Report #A502222-945 CBE Crossmatch Report 5 3 Years Unless Part of an Overpayment Package
Report #R1581730 - Bendex 7 Keep Latest
Report #R8465295-01 ICL Code C 5 3 Years
Report #8300200 - FCRC copy of Form 360AC, Notice of Denial of Application for SNAP 2 3 Years
SSA Card, Copy 3 Permanent
SDX Entitlement 7 Keep Latest Copy
Terminal Clearances 1 Keep Copies from each Filed Application Destroy Duplicate Information
Wage Stubs 7 Record on 2201/Return to Client
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