Forms and Documents 400-28-165

(New 2/1/2024)

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Form Number Form Name Description
SFN 23 Application for Approval for Relative Child Care Provider To be completed by an individual choosing to become an approved relative provider for child care.
SFN 29 Crossroads Program Application To be completed by an individual under age 21 choosing to apply for assistance under the Crossroads Program
SFN 162 Request for Hearing Used when an applicant or caretaker chooses to request a fair hearing due to action taken regarding TANF benefits.
DN 241 Sliding Fee Schedule The Child Care Sliding Fee Schedule was developed to determine cost sharing by a family and Child Care Assistance Program based on income, size of the family, the age of the child, type of provider and level of care
SFN 405 Application for Assistance Used when an individual wishes to apply for multiple programs including the Child Care Assistance Program (CCAP).
SFN 413 Individual Indian Monies Account

SFN 413, Individual Indian Monies Account form is to obtain definite information from Indian agencies about deposits made to and balances remaining in IIM Accounts. This information is necessary to determine eligibility and benefit amount and lends itself to prorating based on income received during a previous 12-month period.

 

The upper portion of the form is to be completed by the eligibility worker. The form must be signed by the applicant and or recipient who then sends or takes it to the superintendent of the Indian agency for completion.

Note: The household may choose to sign a Release of Information permitting the eligibility worker to obtain the needed data from the Indian agency directly. SFN 413, signed by the applicant or recipient, must also be used when this method is followed.

 

The bottom portion of the form is completed by appropriate officials of the Indian agency.

 

IIM accounts for persons enrolled at the Fort Totten and Turtle Mountain Indian agencies are maintained in the Aberdeen, South Dakota, Area Office. Accounts for persons enrolled by the Fort Berthold and Standing Rock agencies are maintained by each of those agencies
SFN 640 Verification of Participation in Alternative Response for Substance Exposed Newborns (ARSEN)

Used by the Child Protective Service (CPS)/case manager when an applicant or recipient is applying for CCAP based on participation in ARSEN.

This form is provided by the CPS/case manager to the eligibility worker who forwards the SFN 640 to State CCAP Policy.
SFN 827 Credit Form Used by eligibility workers to submit payments to the State Office.
SFN 1087 Legal Service Organizations To be provided to individuals suspected of having committed intentional program violation of the availability of free legal services.
SFN 1940 TANF/SNAP/CCAP Notice of Suspected Intentional Program Violation

SFN 1940 is intended to:

  1. Notify an individual in writing when that individual is suspected of having committed intentional program violation;

  2. Provide a means of waiving the right to a hearing if an individual suspected of intentional program violation wishes to waive their right to an administration disqualification hearing;

  3. Assign a hearing time if the right to an administrative disqualification hearing is not waived; and

  4. To allow an individual who desires that a hearing officer be present at the hearing, rather than having a telephone hearing, to indicate that desire.

Form completion instructions:

Pages 1 and 2 are to be completed by the Human Service Zone (HSZ) initiating the administrative disqualification hearing procedure. The form is to be signed in this section, by an eligibility worker, supervisor, or county director who will be present at the meeting with the individual suspected of having committed intentional program violation.

 

Page 3, the "Waiver of Hearing" section, either A or item B, is to be signed if the individual wishes to waive their right to an administrative disqualification hearing.

 

Page 4, the individual suspected of intentional program violation must sign on this page if the individual does not waive their right to a hearing and desires that a hearing officer be present at the hearing, rather than a telephone hearing.

 

If an administrative disqualification hearing is scheduled, the Appeals Referee Supervisor will complete "notice of hearing" and so advise the suspected individual.

Form distribution:

Original

  • If it is decided at the time of the meeting that there was no intentional program violation - file original and all copies in case file along with a notation of the results of the meeting.

  • If the right to hearing is waived, or if there is to be a hearing - forward to Appeals Referee Supervisor.

1 Copy - If the right to a hearing is waived, or if there is to be a hearing - give to the accused individual signing the form.

1 Copy – Case file.

 

 

All forms are available through the Department of Health and Human Services. Some forms may be obtained electronically through E-Forms.

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.