2020-08-17 · Application to Participate in the Family PACT Program (DHCS 4468) Family PACT Program Provider Agreement (DHCS 4469) The following forms are available for download on the Forms page of the Family PACT website. Download Client Eligibility Certification and Retroactive Eligibility Certification forms.
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Household Member Information Form (PA 6091) Important Information About Benefit Overpayments (PA OP/OI 2) Authorization for Reimbursement of Interim Assistance Initial Claim or Posteligibility Case (SSP 14) Homeless General Relief Emergency Housing/Food Assistance Decision (ABP 532) Physical Health Assessment for General Relief (ABP 1676-1)
58/193 Intergenerational transfer. Los Angeles County, California Top 10 Requested Forms : Description Properties; 1 Application Supplement for Hazardous Substances Underground Storage Permit to maintain UST. (38-0012) - To file for a hazardous materials underground storage permit, application supplement, or notice to file authorization to maintain underground storage tanks under the Los Angeles County Unified Program Permit. Form filed monthly with the employer s insurer by the injured worker to report any earnings (Workers' compensation) Keywords ldol-wc-1020, ldol, wc, 1020, employee, monthly, report, earning By signing this form: • I understand and certify, under penalty of perjury, that all my answers on this report are correct and complete to the best of my knowledge. • I understand the penalties for fraud are as follows: I may be sent to prison for up to 20 years and fined up to $250,000.
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