WAG 25-13-00 IES Forms

* Fingerprinted
Barcoded		 Agency Form # Form Name Consolidated Forms Purpose Recipient Print Mode Trigger Method
IL444- 0008 Report of Real and Personal Property Form is sent by caseworker to Bureau of Collections to verify real personal property. Bureau of Collections Local None Manual
IL444- 0034 Consent to Release Information Form is used for when the customer gives permission to office obtain third party information. Customer Local or Central None Manual
* IL444- 0051 Assistance to the Blind, Report of Eye Examination Form is used by the customer's Optometrist to report the status of their eye health condition. Customer Local None Manual
IL444- 0065 Appeal Withdrawal Agreement Form is used by the customer to withdraw their appeal. Customer Local or Central None Manual
IL444- 0085 Case Transfer This form is used to notify the customer of a change in their FCRC. Customer Local or Central Case transfer to a new FCRC in IES Systematic
IL444- 0097 Verification of Birth, Marriage, Divorce, Death This form is mailed by the caseworker to IDPH Division of Vital records to verify information. IDPH Division of Vital Records Local None Manual
IL444- 0102 Statement of Facts This form used by the caseworker to describes customer's appeal and FCRC's position. Customer Local or Central None Manual
* IL444- 0103 Appeal Request Form DHS This form is used by the customer to appeal a local or central office action, inaction, decision, determination, response to a report form, or any issue of policy that the individual disagrees with. Customer Local None Manual
* IL444- 0103KC Appeal Request From HFS This form is used by the customer to appeal a HFS office's action, inaction, decision, determination, response to a report form, or any issue of policy that the individual disagrees with. Customer Local None Manual
IL444- 0183A Medical Evaluations - Physician Report This form is used by the customer's physician to report the status of their health condition. Customer Local or Central Attached to VCL when cases are pending for CAU documents Manual; Systematic
* IL444- 0243 Request for Assistance for Additional Family Member This form is used by the customer to request a family member be added to their case. It is used for active medical only cases and there is a request to add a non-filing unit member to a TANF case. Customer Local None Manual
HFS 0243A Request for Medical Benefits for Another Family Member A, B and C This form is used by the customer to request the addition of family member to an active Medical only case. Customer Local None Manual
HFS 0243B Request for Medical Benefits for Another Family Member A, B and C This form is used by the customer to request the addition of family member to an active Medical only case. Customer Local None Manual
* HFS 0243C Request for Medical Benefits for Another Family Member A, B and C This form is used by the customer to request the addition of family member to an active Medical only case. Customer Local None Manual
HFS 0243KC Request for Prior Coverage This form is used by the customer to request prior month's coverage for All Kids Share or Premium. Customer Local or Central Prior months are certified in IES as approved or denied on an active case. Manual
HFS 0243KC AB Prior coverage Notice of Decision 0243KCA and 0243KCB This form notifies a family of their prior coverage request. Customer Local or Central Prior months are certified in IES as approved or denied on an active case. Systematic
HFS 0243NB Request for Newborn Backdate (Premium Level 2) This form is completed by the customer to request backdated months for Premium Level 2 for a Newborn and to activate payment to Bureau of Fiscal Operation (BFO). Customer Local None Manual
IL444- 0266 Request for Employment Verification This form is sent by the caseworker to an employer to verify earning. Customer or Employer Local None Manual
IL444- 0267L Notice of Missed Interview This form is generated when a SNAP applicant misses an interview at initial application. This notice does not apply to REDEs in service coordination. Customer Central As part of new scheduling module when an appointment date has passed and status is still "Scheduled", nightly batch job will switch status to "No Show" which will trigger this notice. Worker may also manually change status to "No Show" which will also generate this notice as part of nightly batch. Systematic
HFS 0267MSP Request for Additional Information for Medicare Savings Program This form is sent to the customer, notifying them of potential eligibility for the Medicare Savings Program (MSP). It is also an application for the MSP. Customer Local or Central Generated for MSP applications received from SSA when there is no known case in IES and not enough information is available for IES intake.
IL444- 0267T Appointment Notice 267 and 1721 This form notifies a customer when IES is used to schedule an interview at the office. Customer Local or Central Systematically generated when an interview is scheduled at local office Systematic
IL444- 0267VCL IES Verification Checklist 267 and 1721 This form is used to notify a customer what verification is needed to process their application or case change. Customer Local or Central When eligibility is run on case and VCL record is created in IES due to pending information. Notice is triggered by worker confirming VCL information on Verification Checklist Summary page after Eligibility Summary and before Certification. Systematic
IL444- 0274 Active SNAP Client's Request for Disaster Supplement SNAP Benefits This form is used by an active SNAP customer to request disaster supplemental SNAP benefits. ` Local None Manual
IL444- 0274A Active SNAP Client's Notice of Decision for Disaster Supplemental SNAP This form is given to active SNAP customer within disaster area in response to IL444-0274 Active SNAP Customers - Application for Disaster Supplement SNAP Customer Local None Manual
IL444- 0360C

Notice of Decision/Change Summary Section

Notice of Decision/Change Medical Section

Notice of Decision/Change Additional Information

Notice of Decision/Change Cash Section

Notice of Decision/Change SNAP Section

 0157, 0157F, 0157P, 0360BCC, 0360BCC-D, 0360E-I, 0360KC, 0360P, 0360VC, 0458BCC, 0458KC, 0458LTC, 0458M, 0458SP, 0458SP-1, 0458VC, 1988, 2383C, 4101, 553GC, 553I This form notifies the customer of approvals, denials, cancellations and changes in eligibility and benefit amount. Customer Local or Central When decision is made in IES to approve, deny, change or cancel benefits for Cash, Medical and/or SNAP and this decision is certified. Systematic
IL444- 0360R Notice of Decision on SNAP Application Missed Interview This form notifies an applicant for SNAP has been denied due to a missed appointment. Customer Local or Central Generated when a SNAP applicant misses an interview at initial application or a redetermination. Systematic
IL444- 0360X Notice of Decision Application Registration Denial New This form is used to notify the applicant of decision to deny any application for assistance during application registration in IES. Customer Local or Central Upon click of Submit on Application Denial/Withdrawal page under Maintain Application Systematic
HFS 0375 Annual Giving Income to Community Spouses or Dependent Family Members Annual Client Notice This notice informs the customer that they may be eligible to give part of their increased social security check amount to their community spouse, children under age 21 or dependent family members. Customer Central Centrally mailed last week of December to LTC individuals based on eligibility COLA mass change above for cases where LTC individual has income diversions budgeted. Systematic
HFS 0380 Annual Notice of Change in Amount Owed for LTC Annual Client Notice This notice informs the customer of the change in the amount owed for Long Term Care. Customer Central Centrally mailed last week of December to residents without a community spouse or dependent family member and for whom the SSA COLA was centrally budgeted. Mailed to LTC individuals based on eligibility COLA mass change above for cases where LTC individual has income diversions budgeted. Systematic
HFS 0385 Annual WIC Notice Annual Client Notice This notice is sent to pregnant women and families with children under age 5 to tell them about the Women, Infant and Children (WIC) program. Customer Central HFS policy decides when to send and identifies selection criteria. Manual Ad Hoc
HFS 0458AK All Kids Approval Notice (Share/Premium Enrollments) This form notifies a family of the approved Child PE coverage and which individuals have been approved. Customer Local or Central Upon Certification of approved AK Premium 1, Premium 2 or Share in enrolled status; send separate form 0360C if there are other programs on case. Systematic
HFS 0458MB/VC Notice of Decision (HBWD/VC) 0458MB, 0458VC This form is used to notify applicant of approval for HBWD or Veterans Care Customer Local or Central Generated when an EDG is approved and certified for HBWD/VC in enrolled status; sent separate form 0360C if there are other programs on case. Systematic
HFS 0458SP-4 Pay In Spenddown Enrollment Form This form is used to offer a spenddown customer enrollment in Pay-In Spenddown. Customer Central Attached to 0360C Notice of Decision/Notice of Change when person is approved and certified in AABD spenddown. Manual; Systematic
HFS 0458SP-5 Pay-In Spenddown Statement This form is used to apply a customer's payment towards AABD spenddown Customer Central At initial enrollment sent when spenddown is unmet and pay-in enrollment status is saved in IES on Medical Expense page. Systematic
HFS 0469 Medical Card This form is used to verify medical coverage for an individual receiving medical assistance. Customer Local or Central

1. When medical benefits (excl SLIB/QI-1) ARE CERTIFIED (new approval) - insert with Form 0360C;

2. When HBWD/Veterans Care application is certified in enrolled status is approved/active after payment of premiums (insert with 0360C)

 3. When Share-Premium application certified in enrolled status is approved after payment of premiums;

4. When individual awaiting organ transplant is certified in unmet spenddown status;

5. When individual is added to medical case/insert with Form 1934A and with Form 3718;

6. When Temporary Cohen medical benefits are authorized;

7. When renewal is processed/insert with Form 2381A; 0360C;

8. When requested by FCRC or HFS office (manual);

9. When person's name or DOB is corrected in IES;

10. When triggered by OIG as investigator cards;

11. When MPE and HPE approvals - sent by itself.

 Manual; Systematic
HFS 0469D DCFS Temporary Medical Card These forms are issued to DCFS when they request a block of temporary cards with medical RINs tied to active eligibility in IES. Customer NA NA
HFS 0469E DCFS Medical Card This form is issued during the application of medical benefits interview when worker answers "Yes" to "Is this a DCFS Application?" Customer Local or Central Upon submission of DCFS application in App Reg. Caseworker answers question "Is this a DCFS Application" as "yes". Systematic
IL444- 0541 Verification of School Attendance This form is completed and sent by the caseworker to a school to verify school attendance. School or Customer Local None Manual
HFS 0643BCC BCC Renewal Form This letter is triggered when a BCC case is up for recertification at 3, 6 or 12 months depending on the type of treatment. Customer Central When a BCC case is due for recertification at 3, 6 or 12 months depending on type of treatment. Systematic
HFS 0643M Medical only REDE MAGI Maximus This form is sent to customers when they are due for a redetermination on a community medical only case in IES. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Form B is triggered when Medical benefits are not able to be auto-re-determined by Eligibility/IES. Systematic
HFS 0643N Medical only REDE Non-MAGI Maximus This form is sent to customers when they are due for a redetermination on a community medical only case in IES. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Form B is triggered when Medical benefits are not able to be auto-re-determined by Eligibility/IES. Systematic
HFS 0643X Medical only REDE LTC Maximus This form is sent to customers when they are due for a redetermination on a LTC medical only case in IES. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Form B is triggered when Medical benefits are not able to be auto-re-determined by Eligibility/IES. Systematic
IL444- 1119 Congratulations on Going Green New This letter is sent to the head of household when a customer is enrolled in electronic notifications for all programs. Customer Central When a customer updates their account in ABE and has responded to validation email successfully. Systematic
IL444- 1253 Premail Action Request This form is sent to request Financial Warrant Unit to issue a benefit check. Financial Warrant Unit Local None Manual
IL444- 1260A Good Cause for Refusal to Cooperate (Child Support) This form is completed and signed by the customer and informs customer about their right to claim good cause for not cooperating with child support enforcement. Customer Local None Manual
IL444- 1721A Instructions to Client New Hire This form is sent to a customer to provide employment verification when the New Hire Registry identifies conflicting income information from what the customer has reported. Customer Central When eligibility mass change identifies a conflict between IES case record and New Hire registry. Systematic
IL444- 1721C Instructions to Customer Earnings Information This form is sent when information received from an electronic source conflicts with income information previously provided by the client to request verifications. Customer Local or Central When department gets conflicting information regarding customer's employment from eligibility mass change above. Manual
IL444- 1893 SNAP, Cash and Medical REDE Form 4002C, Form 643GC This form is sent to customers when they are due for redetermination for Cash, Medical and/or SNAP in IES. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Form A is triggered when Medical benefits are successfully auto-re-determined by Eligibility/IES. Systematic
IL444- 1934 Notice of Decision on Request This form is sent to customers about a decision made on request for Cash assistance increase or special authorization. Customer Local or Central None Manual
IL444- 1952 Notice of Extension of Time Limitation for Disposition of Application This form is sent to the customer when time extension is granted to obtain missing third party verification. Customer Local or Central None Manual
IL444- 1989 Request for Replacement of Destroyed Food This form is used by a customer to request replacement of destroyed food due to a disaster or a power outage. Customer Local or Central None Manual
IL444- 2151 Referral Form This form is used to inform customers of a referral that was made to a resource in the Resource Directory and the appointment time for this referral. Customer Local or Central Generated when worker submits a referral by clicking submit button on referral information page in IES. Systematic
HFS 2286 Healthy Kids Screening Due This form notifies the customer that a child on their case may be due for a Healthy Kids Checkup. Customer Central Notice generated one month prior to child turning 2 months, 4 months, 6 months, 9 months, 1year, 15 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10 years, 12 years, 14 years, 16 years and 18 years. Systematic
* IL444- 2304 Verification of Pregnancy This form is used by the customer or the office to verify pregnancy. Customer Local or Central None Manual
HFS 2350 Possible Entitlement to Temporary Medical Assistance (Cohen) This form notifies the applicant of the delay in processing their medical application and informs them of possible entitlement to temporary medical assistance. Customer Local or Central Cohen schedule requires letter to be sent to applicant by 54th or 69th day. (FHP/ACA/Aged/Blind or Disability app respectively). By day 44 or day 59, determine if delay is caused by department. Systematic
* HFS 2378DR Declaration of Resources New (not in IES yet)
HFS 2379 Possible Eligibility for Payment Cohen Court Order This form notifies a customer of their potential eligibility for compensatory payment due to the department's delay. Customer Central

Last day of each month to complete Cohen Determination for previous month.

IES will identify if 96% threshold is met.

If less than 96% (i.e. even 95.9%) of cases have been disposed timely based on this calculation, send Form 2379 to all approved cases included in current Cohen Determination processed untimely and marked as Department Delay upon certification in IES. "Disposed timely" is identified by new Eligibility screen before certification that captures delay reason. All delay reasons are used in determination of 96% threshold and only "Department Delay" is used when determining which cases should receive Form 2379.

 Systematic
HFS 2379MB/VC Additional Months Coverage (Healthcare for Workers with Disabilities and Veterans Care. MB and VC consolidated into one This form is used to notify eligible persons upon approval that they can have backdated months if they pay for them. Customer Central Generated as attachment for form 458MB-VC and 3712 when a case is approved and certified for HBWD or Veteran's care. Inserted as an attachment to Form 0360C Systematic
HFS 2381 Medical Benefits: Time to Renew (Medical Only) New This form is sent to the customer when they are due for a redetermination. Provides information on completing Form 643 Medical Redetermination. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Systematic
HFS 2381A Medical Redetermination Notice (Auto-renew medical; REDE due for Cash/SNAP) New This form notifies customer that an auto redetermination was completed for their medical benefits. Sent separately from Form 1893. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Sufficient electronic data to auto-renew medical. Systematic
HFS 2381B Medical Benefits: Time to Renew (Cash/SNAP and Medical renewal) Mailed with 1893 REDE form. New This form is sent with Form 1893 and notifies customer additional information is needed for the medical redetermination. Customer Central Part of eligibility REDE batch job 75 days prior to certification end date in IES. Form B is triggered when Medical benefits are not able to be auto-re-determined by Eligibility/IES. Systematic
HFS 2431 Application for Medical Assistance-Short Form This form is used by the customer to reapply for medical assistance when the application is made within 4 months of the last month a spenddown case was active. Customer Local (cannot be printed centrally by itself) Attached to 0360C when case is cancelled due to being in unmet spenddown for 3 months. Manual; Systematic
2432 Split Bill Transmittal Not in IES yet
HFS 2491 Prehearing Appeal Meeting Appointment Letter This form notifies a customer/appellant of their pre-hearing appointment. Customer Local or Central Upon request of an appeal in IES through appeals screens. Systematic
IL444- 2501A Notice of Direct Deposit This form is used to notify the customer of the start date of the customer's cash benefits being placed in direct deposit. Customer and Protective Payee Local or Central Sent first regular roll month of Direct Deposit status on an existing case. Systematic
IL444- 2501B Notice of Direct Deposit Change This form is used to notify customer of a change in direct deposit due to a change in bank account information. Customer Local or Central Sent when direct deposit info is changed in IES on a case. Systematic
IL444- 2501CF Notice Regarding Your Direct Deposit Request This form is used to notify protective payee and customer of the direct deposit start date for cash. Customer and Protective Payee Local or Central Sent when customer requests Cash Assistance with Direct Deposit Systematic
IL444- 2503G Participation Review Notice This form is used to contact customer about SNAP E&T Activity Customer Local or Central None Manual
HFS 2538C Using Department On Aging Community Care Program to meet Spenddown This form is sent to the customer to notify them that their spenddown is being met with the cost of their services. Customer Local or Central Attached to 0360C when person is approved and certified in DOA spenddown. This is an HFS form - defer to HFS. Manual; Systematic
IL444- 2540 Verification of Living With This form is used when school is not in session for customer to provide to an unrelated individual to verify a child is living with customer. Also used to verify presence of child in home who is not school age. Customer Local None Manual
IL444- 2646 SNAP Work Registration Notice This form is given to customers who are not exempt from SNAP work Registration. Customer Local None Manual
IL444- 2655 Information Regarding Child Support Pass Through Payment This form is used to notify the customer of a pass through payment mail date and amount. Customer Central Triggered by interface via IES with HFS. Each month, daily pass through amounts are summed based on individual IDS and if exceed $50 amount is rounded down to $50 for that month. Systematic
IL444- 2690 Notice of Decision on Request for Crisis Assistance This form notifies customer of decision on request for Crisis Assistance. Customer Local or Central Systematically generated in response to Form 2689 Request for Crisis Assistance with TANF Cash is certified in IES with a crisis assistance supplement approved or denied. Systematic
IL444- 2691 Filing Unit Notice This form is sent when additional information is requested on a person required to be added to a TANF Cash case. Customer Local or Central None Manual
IL444- 2790 Self-Employment Record This form is used by the customer to document self-employment income and business expense. Customer Local or Central Attached to VCL for a self-employment record. Manual; Systematic
IL444- 2827 Notice of Decision on Status This form notifies customer of their request for an exemption form TANF work and training activities. Customer Local or Central None Manual
IL444- 2846 Reconciliation Appointment This notice is sent to schedule an appointment to discuss reconciliation when a customer is not cooperating with a TANF work and training activity or with child support service activity. Customer Local or Central None Manual
IL444- 2846A Reconciliation Agreement This form is completed and signed by the customer and the caseworker when an agreement has been reached regarding cooperation with work and training or child support services. Customer Local or Central None Manual
IL444- 2846G SNAP E&T Conciliation Appointment Notice This form is used to schedule a conciliation meeting prior to sanctioning an individual receiving SNAP. Customer Local or Central None Manual
IL444- 2890 SNAP and TANF Midpoint Report New This form is sent to customers who are due for a Mid-Point report. Customer Local or Central Systematically triggered prior to mid-point report due date. Systematic
IL444- 3159A Notice of Benefit Direct Deposit This form is used to notify the customer or protective payee/guardian each time a check is deposited into their bank account. Customer Local or Central Each time a check is direct deposited in the customer's or payee's bank account. Systematic
IL444- 3180 Agreement to Meet Program Requirements This form is signed by the customer when they agree to cooperate with activity or child support requirement. Customer Local None Manual
IL444- 3324 Change in Reporting Requirements This form is sent when the customer is no longer in Simplified Reporting and now has different reporting requirements. Customer Local or Central Generated when a change certified in IES results in removal of a case from Simplified Reporting status (no longer a simplified reporting eligibility indicator).
HFS 3358 End of Eligibility for Medical Assistance This form is used to notify recipients whose unmet spenddown coverage is ending. The notice includes a blurb about FHP eligibility. Customer Local or Central At system cutoff when spenddown hasn't been met for 2 months. Systematic
HFS 3360A Important Notice About Your Medical Benefits (med ext.) This form is used to notify the customer they are no longer eligible for medical benefits - medical extension approved Customer Local or Central When a Medical Extension is approved and certified in IES due to increase in earned income or spousal support. Systematic
HFS 3361 Redetermination Form (Ext. Medical cases) This form is sent when a case is due for redeterminations for Medical Extension Cases in IES. Customer Central For medical extension cases in months 3 and 7 of their 12 month certification period. Systematic
IL444- 3363 Notice of Benefit Restoration (all programs) This form is sent to the customer when a decision to reduce/cancel assistance has been revised due to an appeal or the original decision being wrong. Customer Local or Central None Manual
IL444- 3410 Confirmation of Appointment for Physical Examination This form is sent to the customer when they are referred to provider as part of medical barrier request. Serves as confirmation of appointment with provider. Customer Local None Manual
IL444- 3430 Congratulations on your New Job (includes medical text) This form is sent to a TANF customer when employment is discovered or reported and has been added to IES case. Customer Local or Central When an interface adds, or a customer reports, a new job this will trigger an eligibility batch for worker to determine eligibility online. As a certification of that result this notice will be generated. Systematic
IL444- 3654 Transfer of Resources New (not in IES yet)
IL444- 3658 Illinois Link Card Issuance Form This form is printed for customer signature when link card is issued in local office. Customer Local None Manual
HFS 3704 You Can Get Help to Buy Health Insurance This form is provided to customer with details on private health insurance through the Health Insurance Marketplace. It is inserted with denial and cancellation of Medicaid coverage notices. Customer Local or Central

An attachment to 0360C Notice of Decision/Change and when individual is referred to FFM.

Denial reasons:

  • Income exceeds program standard (after all case progression has occurred and if appropriate, unmet spenddown isn't met)
  • Value of resources exceeds limit for AABD/HBWD (unmet spenddown isn't met)
  • Adult does not meet immigration requirement however is determined lawfully present (any document in IES list should suffice). Do not refer or send notice to undocumented noncitizens. Group also includes persons approved for emergency medical for ineligible non-citizens. At least one person who is denied does not have Medicare. If all person being denied have Medicare and are denied for one of reasons listed above, do not insert 3704 with 0360C.
 Manual; Systematic
HFS 3712MB/VC To Start Your Coverage (HBWD/VC) This form is sent to notify HBWD and Veterans Care customers of their monthly premiums. Customer Local or Central An attachment to 0458MB/VC HBWD/VC Notice of Enrollment when case is enrolled in HBWD/VC in IES and certified. Systematic
HFS 3726A Information Regarding Co-Pays 3726 and 3726A This form is sent to customers, providing information on AllKids copays. It includes a tracker form. Customer Central Attached to 0360C approval and renewal notice when case has at least one person approved for AK Share or Pr1. Manual; Systematic
HFS 3771A Reinstatement (all medical programs) This form is sent to customer when a medical case is reinstated and certified in IES. Customer Local or Central Sent when medical is reinstated. Manual; Systematic
HFS 3780D Temporary Eligibility for SASS (194 cases) This form is provided to children under 18 who are seeking public funding for psychiatric services through DHS. Identifies non-HFS enrolled children's eligibility for services through SASS. Customer Local or Central None Manual
HFS 3795 BCC Recertification and Physician Statement This form is sent when a BCC case is up for recertification. Customer Central When a BCC case is due for recertification at 3, 6 or 12 months depending on type of treatment. Systematic
HFS 3806 HFS Privacy Policy This form is sent to the customer to notify them of HFS's privacy policy for medical information that the customer provided Customer Local or Central As an attachment to all medical (including MSP) 0360C approval notices and initial denials. Not sent on 0360C for changes. Manual; Systematic
HFS 3818 Temporary Medical Benefits (Child PE approved) This form notifies a family of the approved Child PE coverage and which individuals have been approved. Customer Central When children on medical application have been approved for Child PE. Systematic
HFS 3818A Temporary Medical Benefits (Child PE denied) This form notifies family of children ineligible for Child PE coverage. Customer Local or Central When children on medical application have been denied for Child PE. Systematic
HFS 3848 Authorization of Direct Debit This form is sent to the customer to provide direct deposit information for the medical premium program. Customer Local or Central An attachment to 0458MB/VC and 0458AK when All Kids, Veterans Care or HBWD Premium programs are approved and certified in IES. Systematic
HFS 3859A Help Sheet for US Citizenship and ID Documentation This form is sent to customers providing information on how to verify citizenship and Identity. Customer Local or Central An attachment to form VCL when citizenship or identity VCL record is created for medical EDG in IES. Systematic
IL444- 4335 Your TANF Time Limit This form is sent at application and each REDE to tell customer how many months of their 60-Month Limit they have used and how many are left. Customer Local or Central None Manual
IL444- 4634 4E Time Limit Warning This form is sent to a family on TANF in month 48 and month 54. TANF edges with one adult relative or two adult relatives and one of them has been determined to have a barrier from work/work training activities. Customer Local or Central Generated when TANF counter is incremented to 48 and 54 months. Systematic
IL444- 4634 6E Time Limit Warning This form is sent to a family on TANF in month 48 and month 54. TANF edges with two work eligible adults. Customer Local or Central Generated with TANF counter reaches 48 and 54 months. Systematic
IL444- 4690C Time Limit Exceptions This form informs the customer of the exception policy when their TANF counter reaches 57. Customer Local or Central Generated when TANF counter is incremented to 57 months. Systematic
IL444- 4691C Request for Exception This form is used by the customer to request a TANF exception. Customer Local or Central Generated as an attachment to 4690C when TANF counter is incremented to 57 months. Additionally, Form 4691C can be manually/locally printed and given to customer if replacing original 4691C attached to 4690C. Systematic
IL444- 4701H Authorization to Release Medical Records This form is signed by the client and allows the office to request medical records. Customer Local None Manual
IL444- 4769 Earned Income Redetermination Fact Sheet This form notifies the customer when they are eligible for Simplified Reporting for SNAP. Customer Local or Central Generated when change certified in IES results in enrollment of case in Simplified Reporting status. Systematic
HRS 643RNW Courtesy Renewal Follow Up Letter This form is sent to a customer as a reminder when a medical case received renewal Form B and no response has been received. Customer Central Generated on 18th of month renewal form is due when there is no packet received date in IES. Systematic

* Form is Fingerprinted and Barcoded