Appendix A Claim Forms

Georgia State Seal

GEORGIA DIVISION OF FAMILY AND CHILDREN SERVICES
BENEFIT RECOVERY POLICY MANUAL

Chapter:

Appendix A

Effective Date:

December 2020

Policy Title:

Claim Forms

Reviewed or Updated in:

MT-12

Policy Number:

Appendix A

Previous Update:

MT-11

Form # Name of Form Revision Date Order Info

269

Form 269 EBT Claim Payment Agreement

10/20

PAMMS

269 SP

Form 269SP EBT Claim Payment Agreement (Spanish)

10/20

PAMMS

486

Form 486 Claims Repayment Agreement

09/20

PAMMS

486 SP

Form 486SP Claims Repayment Agreement (Spanish)

09/20

PAMMS

5667

Form 5667 Request for Case Review

02/18

PAMMS