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Appendix B: Medical Assistance Automated Renewal Forms Form NumberDescriptionPA 1795Household Members/Living ExpensesPA 1796Household Composition Verification StatementPA 1809Citizenship and Identity InformationPA 1819Affidavit Attesting to Identity of Minor Child31 more rows
WRITING FROM THE DEPARTMENT, TO DISCLOSE ANY MONEY IN SALARY, WAGES, COMPENSATION, AND THE AMOUNTS AND DATES OF SUCH SALARY. THE DEPARTMENT CERTIFIES THAT THE EMPLOYEE BELOW IS APPLYING FOR, RECEIVING OR DID RECEIVE PUBLIC ASSISTANCE, OR IS A LEGALLY RESPONSIBLE RELATIVE OF THE EMPLOYEE.
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