Economic Self Sufficiency Forms
Economic Self Sufficiency Forms
DCF Forms
For a complete listing of DCF forms visit: https://myflfamilies.com/forms
Application Forms
The quickest way to apply for Government Assistance is online through the MyACCESS portal. Individuals can also make changes, apply for additional assistance, check case status and more using the MyACCESS Portal. If you are unable to apply online and need a paper application, please use the forms below. Please note that only one application is needed, whether you apply online through the MyACCESS portal or use a paper application below.
- Family-Related Medicaid Application
Print and fill out this application if you are pregnant or have children age 20 or younger living with you and only want to apply for Medicaid. - Government Assistance Application
Print and fill out this application if you want to apply for Food Assistance and/or Temporary Cash Assistance, and Medicaid.
General Program Forms
- Change Report Form (opens in new window)
- Child Support Cooperation Good Cause / Refusal to Cooperate (opens in new window)
- Child Support Cooperation Notice (opens in new window)
- Financial Information Release (English and Español) (opens in new window)
- Hearings Request for Government Assistance (opens in new window)
- Rights and Responsibilities (opens in new window)
- Sample Fax Cover Sheet (PDF, opens in new window)
- Verification of Dependent Care Expenses (opens in new window)
- Verification of Employment/Loss of Income (opens in new window)
- Verification of Shelter Expenses (opens in new window)
- Work Calendar (to report self-employment income) (opens in new window)
Food Assistance Program Forms
Temporary Cash Assistance Program Forms
Medicaid Program Forms
- Appointment of a Designated Representative (opens in new window)
- Assignment of Rights to Support for Institutional Care Program (opens in new window)
- Authorization to Disclose Information (opens in new window)
- Designation of Beneficiary (opens in new window)
- Designation of Resources for Burial Funds (opens in new window)
- Informed Consent Long Term Care Assessment (PDF, opens in new window)
- Life Insurance Verification Request (opens in new window)
Completed forms can be uploaded to your MyACCESS account. Completed forms and/or paper applications may also be mailed to the Office of Economic Self Sufficiency Mail Center, P.O. Box 1770, Ocala, FL 34478-1770, faxed to 1-866-886-4342, or hand-delivered to a Family Resource Center. Please note, the quickest way to apply for government assistance or submit forms is through the MyACCESS portal.