Forms

State/County Special Assistance for Adult Forms
Title Effective Date
DAAS 20201 Special Assistance Second Party Review Form APPLICATIONS May 15, 2020 02:14 PM
DAAS 20202 Special Assistance Second Party Review Form RECERTIFICATIONS May 15, 2020 02:13 PM
DAAS-3000 Appointment Follow-up Letter Regarding SA Assistance Request Oct 01, 2011 12:05 PM
DAAS-3000sp Carta de seguimiento para hacer una cita Oct 01, 2011 12:05 PM
DAAS-3001 Special Assistance Notice of County of Residence Reassignment/Transfer Oct 01, 2011 12:30 PM
DAAS-3001sp Notificación sobre reasignación o transferencia Oct 01, 2011 12:05 PM
DAAS-3002 Agreement to Sell Property Dec 01, 2011 12:30 PM
DAAS-3002sp Compromiso de venta propiedad Dec 01, 2011 12:05 PM
DAAS-3003 Important Information About Your Special Assistance and Your Resources Dec 01, 2011 12:35 PM
DAAS-3004 Referral to SSA for Waiver or Reduction of Overpayment Recoupment Dec 01, 2011 12:40 PM
DAAS-3005 Documentation Regarding Continuation of Special Assistance When the LOC Is Upgraded, But No Bed Is Available Dec 01, 2011 12:05 PM
DAAS-3006 Medical Care Special / Medical Expense Form Dec 01, 2011 12:40 PM
DAAS-8190 SSI/Non-SSI Application Workbook Jun 01, 2017 12:50 PM
DAAS-8191 Special Assistance Re-enrollment Information Notice Nov 01, 2015 10:35 AM
SAIH Appendix A, State/County Special Assistance (SA) Flow Sheet Jun 14, 2013 10:35 AM
Appendix E, SAICHM Program Interagency Transmittal Form Sep 30, 2019 03:35 PM
SAIH Appendix E, Supplement 1 Feb 10, 2020 10:35 AM
SAIH Appendix E, Supplement 2 Feb 10, 2020 10:35 AM