Applications and Forms

Page 3 of 3

• W-1226S

  Proof of Food Loss Form - Spanish

• W-300MED

  W-300MED - For Medicaid for the Employed Disabled - Rev. 12-19

• W-300SA

  W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19

• W-300T19

  W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19

• W-650

  W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10

• W-650S

  W-650S - Autorización para Reembolso de Asistencia Interina - Rev. 09/10

• W-675

  W-675 - Report Form For Protective Services For The Elderly - Rev. 06/23

• W-682

  W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23

• W-682S

  W-682S - FORMULARIO DE AUTORIZACIÓN DE DEPÓSITO DIRECTO - Rev. 1-23

• W-944

  W-944 - Notice of Action - Rev. 05-23