65A-1.400. Forms for Client Notice and Contact  

Effective on Monday, June 4, 2018
  • 1The following forms are used for Public Assistance Programs to provide applicants and recipients with required notice of the agency’s and client’s rights and responsibilities and other necessary program information. These forms are hereby incorporated by reference.

    38(1) Forms that apply to two or more public assistance programs are:

    50(a) CF-ES Form 1007, Oct 05, Office of Appeal Hearings Hearing Request

    62(b) CF-ES Form 2064, Mar 12, Your Rights and Responsibilities

    72(c) CF-ES Form 2304, Sep 02, Public Assistance Consent to Release Information

    84(d) CF-ES Form 2305, Oct 05, Relative Caregiver Program Request for Eligibility Consideration

    97(e) CF-ES Form 2332, Mar 05, Appointment Notice for Face-to-Face Interview

    108(f) CF-ES Form 2333, Mar 05, Eligibility Redetermination Letter

    117(g) CF-ES Form 2334, Mar 05, Request for Information

    126(h) CF-ES Form 2335, Mar 05, Request for Information for Elderly and Disabled Individuals

    140(i) CF-ES Form 2336, Nov 06, Interim Contact Letter

    149(j) CF-ES Form 2640, May 05, Temporary Cash Assistance (TCA)/Medicaid/Food Stamp Program Child Support Cooperation Notice

    165(k) CF-ES Form 2641, May 05, Claim Notice – Good Cause for Refusal to Cooperate

    180(l) CF-ES Form 2672, Oct 05, Real Property Agreement

    189(m) CF-ES Form 3052A, Feb 09, Change Report Form

    198(n) CF-ES Form 3103, Sep 02, Authorized Benefit Representative for Electronic Benefit Transfer

    211(2) The Food Stamp Program only forms are:

    219(a) CF-ES Form 2095, May 05, Food Stamp Work Registration Notice

    230(b) CF-ES Form 2331, Jan 05, Food Stamp Application for SSI Applicants

    242(c) CF-ES Form 3010, Feb 09, Authorized Representative Designation

    251(3) The Medicaid only forms are:

    257(a) CF-ES Form 990, Sep 02, Designation of Beneficiary

    266(b) CF-ES Form 1056, Feb 03, KidCare Program Notice of Case Action

    278(c) CF-ES Form 2039, Apr 03, Medical Assistance Referral

    287(d) CF-ES Form 2040, Feb 03, Informed Consent Form

    296(e) CF-ES Form 2059, Sep 02, Consent of Disclosure Statement

    306(f) CF-ES Form 2099, Jul 02, Medicaid Application for Breast and Cervical Cancer Treatment

    320(g) CF-ES Form 2277, Oct 05, KidCare Program Medicaid Eligibility Review

    331(h) CF-ES Form 2293, May 10, Child in Care Medicaid Application

    342(i) CF-ES Form 2514, Jul 03, Authorization to Release Medical Information

    353(j) CF-ES Form 2613, Oct 05, Financial Information Release

    362(k) CF-ES Form 2635, Sep 02, Protective Payee Agreement

    371(l) CF-ES Form 2700, May 10, Health Insurance Application for Pregnant Women

    383(m) CF-ES Form 2701, Feb 03, Request for Length of Treatment Information

    395(n) CF-ES Form 2930, Apr 07, Screening for Expedited Medicaid Appointment

    406(4) The Overpayment and Benefit Recovery only forms are:

    415(a) CF-ES Form 3400, Feb 2018, Request for Additional Information

    425(b) CF-ES Form 3410, Feb 2018, Waiver of Administrative Disqualification Hearing With a Program Loss

    440(c) CF-ES Form 3410A, Feb 2018, Waiver of Administrative Disqualification Hearing Without a Program Loss

    455(d) CF-ES Form 3414, Nov 07, Disqualification Consent Agreement

    464(e) CF-ES Form 2338, Feb 2018, Contact Notice

    472(f) CF-ES Form 2339, Feb 2018, Request for Verification

    481(g) CF-ES Form 2340, Feb 2018, Home Visit Confirmation Notice

    491(5) The Temporary Cash Assistance only forms are:

    499(a) CF-ES Form 2082, Sep 05, Hardship Extension/Exemption Review

    508(b) CF-ES Form 2094, Jun 09, Statement of the Need for Care

    520(c) CF-ES Form 2097, Oct 05, Communication and Work Activity Referral

    531(d) CF-ES Form 2299, Feb 03, Alcohol, Drug Abuse and Mental Health (ADM) Treatment Verification

    546(e) CF-ES Form 2601, Feb 03, Temporary Cash Assistance Program Refugee Assistance Program

    559(f) CF-ES Form 4192, May 05, Notice of Work Penalty

    569The edition date on some forms is listed with a notation that the edition replaces a previous edition that may still be used. This notation is to indicate that the new edition of the form does not implement a policy change and that supplies of the previous edition of a specific form may be exhausted prior to the use of the new edition.

    632(6) Copies of materials incorporated by reference are available from the ACCESS Florida Headquarter’s Office, 1317 Winewood Boulevard, Tallahassee, Florida 32399-0700, or on the Department’s website at http://www.dcf.state.fl.us/DCFForms/Search/ DCFFormSearch.aspx. 661Forms CF-ES 3410, CF-ES 3410A, CF-ES 2338, CF-ES 2339, and CF-ES 2340 can also be found at 678http://www.flrules.org/Gateway/reference.asp?No=Ref-09355; 680http://www.flrules.org/Gateway/reference.asp?No=Ref-09356; 682http://www.flrules.org/Gateway/reference.asp?No=Ref-09357; 684http://www.flrules.org/Gateway/reference.asp?No=Ref-09358; 686and 687http://www.flrules.org/Gateway/reference.asp?No=Ref-09359, 689respectively.

    690Rulemaking Authority 692409.919, 693410.033, 694414.45 FS. 696Law Implemented 698409.903, 699409.904, 700410.033, 701414.065, 702414.075, 703414.085, 704414.095, 705414.105, 706414.115, 707414.122, 708414.31 FS. 710History–New 4-9-92, Amended 7-1-93, 8-3-94, Formerly 10C-1.400, Amended 12-29-98, 3-18-03, 7-25-06, 1-8-12, 6-4-18.