Forms and Information

• Use the following forms for Public Assistance programs only.
• Refer to our offices for other forms not listed here.
• These forms are updated regularly. Please use the links below for the most current form

One Fax for All Offices
DPA’s statewide toll-free fax number is 888-269-6520, and Anchorage area residents can dial 907-269-6520.

• Applications for Public Assistance

General

• Direct Deposit Request (GEN 153)
  Form used to set up a new direct deposit or change bank account information on an existing direct deposit for cash assistance programs (Senior Benefits, Adult Public Assistance, Temporary Assistance)
• Eligibility Review Form (GEN 72)
  Form used to renew or recertify eligibility for most DPA programs
• Request for Case File Records (GEN 35)
  Form used to request documents from a DPA case file

Informational

• Denali KidCare Outreach Flyer (MED 34)
  Promotes Medicaid benefits for children and pregnant women, and provides the monthly income limits
• Preparing for your Fair Hearing (DPA 5)
  Provides information about how to prepare for a public assistance fair hearing
• TEFRA Brochure (MED 15)
  Provides information about how children with disabilities living at home may qualify for Medicaid benefits
• Temporary Assistance Penalty Brochure (TA 14)
  Describes penalties that may occur for certain Alaska Temporary Assistance Program participants

Supplemental Nutrition Assistance Program (SNAP)

(Formerly Food Stamps)

• SNAP Make America Stronger Pamphlet (FSP 313)
  Promotes SNAP benefits and provides the monthly income limits and maximum allotments
• SNAP Requirements for Eligibility (FSP 79)
  Overview of SNAP eligibility requirements
• SNAP Simplified Reporting Flyer (FSP 82)
  Provides information about reporting requirements for SNAP households

Medicaid Trusts

• Qualifying Income Trusts (MED 23)
  Provides information about establishing a Qualifying Income Trust (aka Miller’s Trust) when an individual has too much countable income to qualify for Medicaid benefits
• Special Needs and Pooled Trusts (MED 22)
  Provides information about establishing a Special Needs or Pooled Trust when a disabled individual has too much countable income or too many countable resources to qualifying for Medicaid benefits