| SFN | Entity | Title | Size | Date | Fillable |
|
15
|
Human Services, Department of
|
Home Health Request for Prior Authorization
|
207 kb
|
10/27/2008
|
Y
|
|
21
|
Human Services, Department of
|
Transmittal Between Units
|
204 kb
|
2/22/2007
|
Y
|
|
23
|
Human Services, Department of
|
Application For Approval For Relative Child Care Provider
|
459 kb
|
3/13/2008
|
Y
|
|
43
|
Human Services, Department of
|
National Provider Identifier (NPI) Registration
|
226 kb
|
|
Y
|
|
52
|
Human Services, Department of
|
Spousal Assets
|
308 kb
|
|
Y
|
|
55
|
Human Services, Department of
|
Statement of Actual Costs - In-home Services
|
78 kb
|
|
N
|
|
62
|
Human Services, Department of
|
Emergency Assistance Application
|
326 kb
|
|
Y
|
|
73
|
Human Services, Department of
|
Partial Hospitalization - Pre-Authorization
|
467 kb
|
3/16/2009
|
Y
|
|
91
|
Human Services, Department of
|
Revocation of Authorization to Disclose Information
|
80 kb
|
|
Y
|
|
107
|
Human Services, Department of
|
Social/Emotional Developmental/Well Being Screening Preliminary Questions
|
339 kb
|
|
Y
|
|
113
|
Human Services, Department of
|
Postsecondary Education Information
|
175 kb
|
|
Y
|
|
123
|
Human Services, Department of
|
Brand Name NSAID/COX2 Prior Authorization
|
193 kb
|
|
Y
|
|
124
|
Human Services, Department of
|
Dispense as Written Prior Authorization
|
176 kb
|
|
Y
|
|
125
|
Human Services, Department of
|
ARB Authorization
|
172 kb
|
|
Y
|
|
126
|
Human Services, Department of
|
ACE Inhibitor Prior Authorization
|
177 kb
|
|
Y
|
|
129
|
Human Services, Department of
|
Alternative to Abortion Services Payment Voucher
|
599 kb
|
5/1/2008
|
Y
|
|
143
|
Human Services, Department of
|
Civil Rights Complaint
|
220 kb
|
2/3/2009
|
N
|
|
152
|
Human Services, Department of
|
Child Support Verification
|
108 kb
|
|
Y
|
|
161
|
Human Services, Department of
|
Direct Deposit Enrollment and Authorization
|
265 kb
|
4/30/2009
|
Y
|
|
162
|
Human Services, Department of
|
Request for Hearing
|
54 kb
|
|
Y
|
|
167
|
Human Services, Department of
|
Determination of Availability of Employer-Based Health Insurance
|
243 kb
|
3/25/2008
|
Y
|
|
168
|
Human Services, Department of
|
North Dakota Medicaid Provider Appeal
|
159 kb
|
|
Y
|
|
171
|
Human Services, Department of
|
Foster Program Subsidized Employment Agreement
|
254 kb
|
9/14/2009
|
Y
|
|
200
|
Human Services, Department of
|
Asset Assessment
|
250 kb
|
|
Y
|
|
205
|
Human Services, Department of
|
Group and Residential Child Care Facilities Annual Review and Statement of Compliance
|
543 kb
|
12/7/2007
|
Y
|
|
209
|
Human Services, Department of
|
Childcare Facility Fire Drill and Smoke Detector Testing Record
|
225 kb
|
|
Y
|
|
223
|
Human Services, Department of
|
Fire Inspection Certification
|
214 kb
|
|
Y
|
|
228
|
Human Services, Department of
|
Workers with Disabilities Report-Part II
|
414 kb
|
|
Y
|
|
229
|
Human Services, Department of
|
Social Contract
|
102 kb
|
|
Y
|
|
234
|
Human Services, Department of
|
Insurance Coverage Statement
|
197 kb
|
|
Y
|
|
235
|
Human Services, Department of
|
Criminal Offense Conviction Statement
|
197 kb
|
|
Y
|
|
236
|
Human Services, Department of
|
Financial Disclosure Statement
|
161 kb
|
|
Y
|
|
252
|
Human Services, Department of
|
Chafee Education and Training Voucher Program (ETV)-
|
256 kb
|
|
Y
|
|
255
|
Human Services, Department of
|
Chafee Foster Care Independence Program Unaccompanied Refugee Minor Program Request for Financial Assistance
|
182 kb
|
|
Y
|
|
269
|
Human Services, Department of
|
Monthly Data and Payment Report
|
569 kb
|
7/30/2009
|
Y
|
|
270
|
Human Services, Department of
|
Request for Replacement Due to Loss of Food Pruchased with Snap Benefits
|
222 kb
|
8/13/2009
|
Y
|
|
296
|
Human Services, Department of
|
ND Family Caregiver Support Program Monthly Report
|
229 kb
|
|
Y
|
|
308
|
Human Services, Department of
|
Medicaid and Basic Care Assistance Programs Provider Agreement
|
172 kb
|
|
Y
|
|
312
|
Human Services, Department of
|
Correction Order Notification and Child Care Provider Confirmation
|
110 kb
|
|
Y
|
|
323
|
Human Services, Department of
|
Jobs Status Change
|
167 kb
|
2/7/2008
|
Y
|
|
327
|
Human Services, Department of
|
Family Foster Care Home Claim of Property Damage
|
176 kb
|
10/16/2007
|
Y
|
|
328
|
Human Services, Department of
|
Family Foster Care Home Property Damage Verification of Claim
|
267 kb
|
10/16/2007
|
Y
|
|
343
|
Human Services, Department of
|
Child Care Documentation Record For TB Testing, CPR, First Aid and Training
|
275 kb
|
|
Y
|
|
351
|
Human Services, Department of
|
Case Activity Log
|
18 kb
|
|
Y
|
|
354
|
Human Services, Department of
|
Child Care Assistance Program Estimate of Day Care Required
|
75 kb
|
|
Y
|
|
373
|
Human Services, Department of
|
Authorization for Background Check/Military/Reservation
|
319 kb
|
12/2/2008
|
Y
|
|
377
|
Human Services, Department of
|
Background Check Address Disclosure/Release of Information
|
380 kb
|
10/9/2009
|
Y
|
|
383
|
Human Services, Department of
|
Death/Serious Accident/Illness or Injury Report
|
268 kb
|
|
Y
|
|
387
|
Human Services, Department of
|
ICPC Supervision Report
|
248 kb
|
2/26/2009
|
Y
|
|
393
|
Human Services, Department of
|
Children with Medically Fragile Needs-Clinical Criteria
|
596 kb
|
4/9/2008
|
Y
|
|
394
|
Human Services, Department of
|
Children with Medically Fragile Needs Application
|
275 kb
|
3/17/2008
|
Y
|
|
410
|
Human Services, Department of
|
Request for Client Assistance Services
|
246 kb
|
8/27/2007
|
Y
|
|
413
|
Human Services, Department of
|
Individual Indian Monies Account
|
205 kb
|
|
Y
|
|
414
|
Human Services, Department of
|
Subsidized Employement Agreement
|
265 kb
|
9/29/2009
|
Y
|
|
416
|
Human Services, Department of
|
Medicaid Application - Women's Way
|
427 kb
|
|
Y
|
|
423
|
Human Services, Department of
|
Kinship Placement
|
111 kb
|
|
Y
|
|
424
|
Human Services, Department of
|
Kinship Care Agreement
|
110 kb
|
|
Y
|
|
427
|
Human Services, Department of
|
Nursing Home Census Data Report
|
93 kb
|
|
Y
|
|
429
|
Human Services, Department of
|
Memorandum Of Agreement To Establish Protective Payments
|
183 kb
|
|
Y
|
|
433
|
Human Services, Department of
|
Child Abuse and Neglect Background Inquiry
|
256 kb
|
5/21/2009
|
Y
|
|
443
|
Human Services, Department of
|
Notice of Right to Claim "Good Cause"
|
96 kb
|
|
Y
|
|
445
|
Human Services, Department of
|
Family Evacuation Disaster Plan
|
400 kb
|
3/16/2009
|
Y
|
|
446
|
Human Services, Department of
|
Request to Claim Good Cause
|
72 kb
|
|
Y
|
|
451
|
Human Services, Department of
|
Eligibility Report on Disability/Incapacity
|
437 kb
|
6/16/2009
|
Y
|
|
471
|
Human Services, Department of
|
Vendor Payment (TANF) Authorization and Request For Payment For Goods and Services
|
304 kb
|
7/14/2008
|
Y
|
|
481
|
Human Services, Department of
|
Service Limits Prior Authorization Request
|
213 kb
|
6/23/2009
|
Y
|
|
502
|
Human Services, Department of
|
Application for Health Care Coverage
|
2015 kb
|
6/16/2008
|
Y
|
|
507
|
Human Services, Department of
|
Step One: Voluntary Treatment Program Application
|
676 kb
|
|
Y
|
|
508
|
Human Services, Department of
|
Authorization for Child Abuse and Negliect Background Check
|
259 kb
|
12/2/2008
|
Y
|
|
509
|
Human Services, Department of
|
Out-of-State Enrollment Clarification
|
78 kb
|
|
Y
|
|
511
|
Human Services, Department of
|
Medical Procedure/Device Prior Authorization Request
|
214 kb
|
11/25/2008
|
Y
|
|
517
|
Human Services, Department of
|
Child Care Evacuation Disaster Plan
|
352 kb
|
4/28/2009
|
Y
|
|
522
|
Human Services, Department of
|
Certificate of Medical Necessity-Speech Generating Device
|
223 kb
|
|
Y
|
|
524
|
Human Services, Department of
|
Certificate of Medical Necessity-CPAP/BiPAP
|
194 kb
|
|
Y
|
|
526
|
Human Services, Department of
|
Certificate of Medical Necessity-Standing Frames
|
254 kb
|
|
Y
|
|
528
|
Human Services, Department of
|
Certifcate of Medical Necessity-Infant Apnea Monitor
|
265 kb
|
7/31/2007
|
Y
|
|
529
|
Human Services, Department of
|
Application: Heating Assistance Program
|
1418 kb
|
7/20/2009
|
Y
|
|
541
|
Human Services, Department of
|
Request to be a Qualified Service Provider for Family Home Care
|
308 kb
|
4/15/2009
|
Y
|
|
560
|
Human Services, Department of
|
Assignment of Benefits
|
177 kb
|
|
Y
|
|
566
|
Human Services, Department of
|
Medicaid Questionnaire and Assignment
|
175 kb
|
|
Y
|
|
598
|
Human Services, Department of
|
Child Care Assistance Application
|
1159 kb
|
6/3/2008
|
Y
|
|
614
|
Human Services, Department of
|
Physician Certification for Sterilization and Recipient Acknowledgement of Sterility
|
261 kb
|
10/20/2008
|
N
|
|
615
|
Human Services, Department of
|
Medicaid Program Provider Agreement
|
150 kb
|
|
Y
|
|
616
|
Human Services, Department of
|
Child Care Billing Report
|
874 kb
|
4/1/2008
|
Y
|
|
620
|
Human Services, Department of
|
Non-Medical Provider
|
160 kb
|
|
Y
|
|
630
|
Human Services, Department of
|
Foster Care Placement Notification & Preliminary Eligibility Determination
|
139 kb
|
|
Y
|
|
634
|
Human Services, Department of
|
Claim Form - Drug/Pharmacy
|
140 kb
|
|
Y
|
|
639
|
Human Services, Department of
|
Provider Request for an Adjustment
|
100 kb
|
|
Y
|
|
640
|
Human Services, Department of
|
Pharmacy Request for an Adjustment
|
89 kb
|
|
Y
|
|
641
|
Human Services, Department of
|
Title IV-E Title XIX Application-Foster Care
|
506 kb
|
6/26/2007
|
Y
|
|
659
|
Human Services, Department of
|
Respite Home Evaluation
|
295 kb
|
|
Y
|
|
661
|
Human Services, Department of
|
Electronic Funds Transfer (EFT)
|
90 kb
|
|
Y
|
|
670
|
Human Services, Department of
|
Child Care Assistance Change Report
|
187 kb
|
6/26/2007
|
Y
|
|
690
|
Human Services, Department of
|
Affidavit of Identity for Disabled Individual in Facility
|
173 kb
|
10/22/2007
|
Y
|
|
691
|
Human Services, Department of
|
Affidavit of Identity For Children
|
229 kb
|
1/4/2008
|
Y
|
|
705
|
Human Services, Department of
|
Health Tracks - Appointment Slip
|
272 kb
|
2/21/2007
|
Y
|
|
706
|
Human Services, Department of
|
Affidavit of Explanation Why Citizenship Cannot be Supplied
|
168 kb
|
9/24/2007
|
Y
|
|
707
|
Human Services, Department of
|
Citizen Affidavit
|
259 kb
|
2/5/2008
|
Y
|
|
710
|
Human Services, Department of
|
Health Tracks - Referral and Request for Information
|
35 kb
|
|
Y
|
|
716
|
Health, Department of
|
CSHS Authorization to Disclose Information
|
476 kb
|
12/13/2007
|
Y
|
|
719
|
Human Services, Department of
|
TANF Request for Benefits
|
353 kb
|
10/23/2007
|
Y
|
|
720
|
Human Services, Department of
|
Certificate of Medical Necessity - Motorized Wheelchairs
|
240 kb
|
|
Y
|
|
722
|
Human Services, Department of
|
Certificate of Medical Necessity - Osteogenesis Stimulators
|
239 kb
|
|
Y
|
|
724
|
Human Services, Department of
|
Certificate of Medical Necessity - Seat Lift Mechanism
|
217 kb
|
|
Y
|
|
725
|
Human Services, Department of
|
Accounting of Disclosure Request
|
50 kb
|
|
Y
|
|
726
|
Human Services, Department of
|
Certificate of Medical Necessity - Parenteral Nutrition
|
196 kb
|
|
Y
|
|
727
|
Human Services, Department of
|
Certificate of Medical Necessity - Section C Continuation Form
|
158 kb
|
|
Y
|
|
728
|
Human Services, Department of
|
Certificate of Medical Necessity - Support Surfaces
|
252 kb
|
|
Y
|
|
729
|
Human Services, Department of
|
Certificate of Medical Necessity - Oxygen
|
237 kb
|
|
Y
|
|
735
|
Human Services, Department of
|
Diversion Assistance-Screening
|
171 kb
|
|
Y
|
|
740
|
Human Services, Department of
|
Initial/Strength/Full Assessment
|
395 kb
|
|
Y
|
|
748
|
Human Services, Department of
|
Individual Request to be a Qualified Service Provider
|
589 kb
|
9/29/2009
|
Y
|
|
749
|
Human Services, Department of
|
Agency Request to be a Qualified Service Provider
|
350 kb
|
4/29/2009
|
Y
|
|
750
|
Human Services, Department of
|
Documentation of Competency
|
236 kb
|
|
N
|
|
757
|
Health, Department of
|
Financial Data Form
|
228 kb
|
5/1/2009
|
Y
|
|
758
|
Human Services, Department of
|
Face and Status Sheet
|
486 kb
|
10/7/2009
|
Y
|
|
760
|
Health, Department of
|
Termination of Children's Special Health Services
|
331 kb
|
9/24/2009
|
Y
|
|
762
|
Health, Department of
|
Orthodontist's Report
|
297 kb
|
9/23/2009
|
Y
|
|
763
|
Human Services, Department of
|
Report of Termination of Adoptive Placement
|
168 kb
|
|
Y
|
|
764
|
Human Services, Department of
|
Notice of Intent to Place DHS Custody Child
|
193 kb
|
|
Y
|
|
765
|
Human Services, Department of
|
Paypoint Pre-Authorization
|
166 kb
|
|
Y
|
|
769
|
Human Services, Department of
|
Request for Prior Authorization for Out-of-State Services
|
512 kb
|
6/17/2009
|
Y
|
|
771
|
Human Services, Department of
|
Report to the Court
|
233 kb
|
|
Y
|
|
778
|
Health, Department of
|
Transfer of Children's Special Health Services
|
400 kb
|
9/15/2009
|
Y
|
|
780
|
Human Services, Department of
|
Certificate of Medical Necessity-External Infusion Pump
|
206 kb
|
|
Y
|
|
781
|
Human Services, Department of
|
Certificate of Medical Necessity-Manual Wheelchair
|
240 kb
|
|
Y
|
|
782
|
Human Services, Department of
|
Certificate of Medical Necessity-Oral and/or Enteral Nutrition
|
241 kb
|
|
Y
|
|
785
|
Human Services, Department of
|
Certificate of Medical Necessity-Hospital Beds
|
237 kb
|
|
Y
|
|
789
|
Human Services, Department of
|
Certificate of Medical Necessity-TENS
|
200 kb
|
|
Y
|
|
790
|
Human Services, Department of
|
Child Care Assistance Program Review
|
692 kb
|
5/28/2009
|
Y
|
|
800
|
Human Services, Department of
|
Fire Safety Self Declaration
|
522 kb
|
1/6/2009
|
N
|
|
805
|
Human Services, Department of
|
Request for an Exemption from the TANF Lifetime Limit
|
160 kb
|
|
Y
|
|
823
|
Human Services, Department of
|
Family Evacuation Disaster Plan
|
361 kb
|
9/11/2008
|
Y
|
|
830
|
Human Services, Department of
|
Request for Client Specific Endorsement
|
133 kb
|
|
N
|
|
832
|
Human Services, Department of
|
Application to be Licensed/Early Childhood Services
|
582 kb
|
12/2/2008
|
Y
|
|
835
|
Human Services, Department of
|
Care Coordination Plan
|
835 kb
|
10/2/2009
|
Y
|
|
838
|
Human Services, Department of
|
Personal Authorization for Criminal History Background Check Inquiry
|
451 kb
|
8/5/2009
|
Y
|
|
841
|
Human Services, Department of
|
Child Care Assistance Redetermination
|
435 kb
|
2/21/2007
|
Y
|
|
845
|
Human Services, Department of
|
Child Information Sheet
|
494 kb
|
3/30/2009
|
Y
|
|
846
|
Human Services, Department of
|
Release of Information-Child Care Facility
|
174 kb
|
|
Y
|
|
847
|
Human Services, Department of
|
Parent's Statement On Health Of Child
|
364 kb
|
3/23/2009
|
Y
|
|
848
|
Human Services, Department of
|
Providers's Request to Pay Parent Directly
|
175 kb
|
6/29/2007
|
Y
|
|
850
|
Human Services, Department of
|
Proton Pump Inhibitor Prior Authorization
|
195 kb
|
|
Y
|
|
851
|
Human Services, Department of
|
Anti-Histamine Prior Authorization
|
179 kb
|
|
Y
|
|
875
|
Human Services, Department of
|
False Claims Education Certification
|
236 kb
|
4/27/2007
|
Y
|
|
898
|
Human Services, Department of
|
Application for License Group/Residential Child Care Facility
|
533 kb
|
12/19/2007
|
Y
|
|
904
|
Human Services, Department of
|
Agreement to Furnish Specialized Family Foster Care Services
|
233 kb
|
8/15/2008
|
Y
|
|
905
|
Human Services, Department of
|
Technology/Procedure Assessment
|
90 kb
|
|
Y
|
|
925
|
Human Services, Department of
|
Home & Community Based Care for the Elderly/Disabled Turnaround Document
|
600 kb
|
7/31/2007
|
Y
|
|
930
|
Human Services, Department of
|
Birthparent Background Information
|
1.1 Mb
|
|
Y
|
|
933
|
Human Services, Department of
|
Request For Privacy Officer Review
|
95 kb
|
|
Y
|
|
934
|
Human Services, Department of
|
Request For Privacy Conference
|
110 kb
|
|
Y
|
|
936
|
Human Services, Department of
|
Acknowledgement of Receipt of the Notice of Privacy Practices
|
87 kb
|
|
Y
|
|
937
|
Human Services, Department of
|
Notice of Placement of Child with Immediate Relative
|
183 kb
|
|
Y
|
|
939
|
Human Services, Department of
|
Report of Adoption/Adoptive Placement
|
650 kb
|
5/21/2009
|
Y
|
|
940
|
Human Services, Department of
|
Search/Disclosure Request
|
330 kb
|
|
Y
|
|
942
|
Human Services, Department of
|
Search/Disclosure Notice of Rights
|
184 kb
|
|
Y
|
|
945
|
Human Services, Department of
|
Certification to the ND Dept. of Human Services
|
201 kb
|
|
Y
|
|
946
|
Human Services, Department of
|
Affidavit
|
167 kb
|
|
Y
|
|
947
|
Human Services, Department of
|
Notice of Intent
|
189 kb
|
|
Y
|
|
948
|
Human Services, Department of
|
Notice of Intent/Guarantee of REsponsibility
|
222 kb
|
|
Y
|
|
960
|
Human Services, Department of
|
Report of Suspected Child Abuse or Neglect
|
44 kb
|
9/11/2009
|
Y
|
|
963
|
Human Services, Department of
|
TCM Assessment
|
380 kb
|
7/2/2008
|
Y
|
|
965
|
Human Services, Department of
|
Interstate Compact on the Placement of Children Request-ICPC 100A
|
253 kb
|
|
Y
|
|
966
|
Human Services, Department of
|
Interstate Compact on the Placement of Children Report on Child's Placement Status-ICPC 100B
|
255 kb
|
|
Y
|
|
970
|
Human Services, Department of
|
Multi-Agency Authorization To Disclose Information
|
2574 kb
|
|
N
|
|
973
|
Human Services, Department of
|
Enrollment Questionnaire
|
98 kb
|
|
Y
|
|
980
|
Human Services, Department of
|
Individual Request to be a Qualified Service Provider/AFFC Provider
|
467 kb
|
5/21/2009
|
Y
|
|
987
|
Human Services, Department of
|
Affidavit of Standard Compliance and Child Care Provider Certification
|
343 kb
|
4/21/2009
|
Y
|
|
989
|
Human Services, Department of
|
Sterilization Consent
|
127 kb
|
|
Y
|
|
1047
|
Human Services, Department of
|
Application for Service
|
182 kb
|
|
Y
|
|
1059
|
Human Services, Department of
|
Authorization To Disclose Information
|
212 kb
|
|
Y
|
|
1077
|
Human Services, Department of
|
Work Activity Report: Self-Employed Person
|
255 kb
|
|
Y
|
|
1078
|
Human Services, Department of
|
Work Activity Report
|
410 kb
|
|
Y
|
|
1084
|
Human Services, Department of
|
Notice of the ND Department of Human Services Determination of Special Needs
|
203 kb
|
|
Y
|
|
1103
|
Human Services, Department of
|
Request for Services
|
329 kb
|
10/13/2009
|
Y
|
|
1115
|
Human Services, Department of
|
Prior Authorization Request
|
446 kb
|
9/8/2009
|
Y
|
|
1130
|
Human Services, Department of
|
Hour by Hour Enrollment and Staffing Schedule for Group Child Care
|
638 kb
|
|
Y
|
|
1168
|
Human Services, Department of
|
Ownership Controlling Interest & Conviction Information
|
368 kb
|
3/12/2009
|
Y
|
|
1169
|
Human Services, Department of
|
Pharmacy Agreement/Medical Assistance Program
|
70 kb
|
|
Y
|
|
1196
|
Human Services, Department of
|
Application for Financial Assistance
|
487 kb
|
6/16/2009
|
Y
|
|
1224
|
Human Services, Department of
|
Medical/Child Support Questionnaire
|
248 kb
|
|
Y
|
|
1422
|
Human Services, Department of
|
Compliance Check List/Family Child Care Homes
|
2225 kb
|
4/22/2009
|
Y
|
|
1423
|
Human Services, Department of
|
Compliance Checklist/Child Care Center
|
3307 kb
|
4/22/2009
|
Y
|
|
1425
|
Human Services, Department of
|
Compliance checklist/Group Child Care
|
3397 kb
|
4/22/2009
|
Y
|
|
1426
|
Human Services, Department of
|
Child Care Record
|
271 kb
|
4/21/2009
|
Y
|
|
1544
|
Human Services, Department of
|
Policies and Procedures Checklist
|
190 kb
|
|
Y
|
|
1545
|
Human Services, Department of
|
Sanitation Inspection Certification
|
212 kb
|
|
Y
|
|
1546
|
Human Services, Department of
|
License Application/Residential Services
|
211 kb
|
|
Y
|
|
1547
|
Human Services, Department of
|
License Application/Day Services
|
210 kb
|
|
Y
|
|
1549
|
Human Services, Department of
|
Governance Statement
|
196 kb
|
|
Y
|
|
1550
|
Human Services, Department of
|
License Termination Request
|
184 kb
|
|
Y
|
|
1551
|
Human Services, Department of
|
License Application Checklist Residential Services
|
176 kb
|
|
Y
|
|
1552
|
Human Services, Department of
|
License Application Checklist Day Services
|
176 kb
|
|
Y
|
|
1555
|
Human Services, Department of
|
Physical Standards Checklist Group Home Facilities
|
346 kb
|
|
Y
|
|
1556
|
Human Services, Department of
|
Plan of Correction
|
159 kb
|
|
Y
|
|
1694
|
Human Services, Department of
|
Search and Copying Services Records Requests
|
162 kb
|
|
Y
|
|
1724
|
Health, Department of
|
Service Plan
|
365 kb
|
6/23/2009
|
Y
|
|
1726
|
Health, Department of
|
Health Care and Family Functioning Tier Assessment Summary Sheet
|
279 kb
|
6/8/2009
|
Y
|
|
1727
|
Health, Department of
|
Health and Specialty Providers
|
258 kb
|
6/23/2009
|
Y
|
|
1763
|
Human Services, Department of
|
Request for Reimbursement-Direct Service
|
288 kb
|
|
Y
|
|
1765
|
Human Services, Department of
|
Request for Reimbursement/Non-State Employee
|
231 kb
|
|
Y
|
|
1818
|
Human Services, Department of
|
MCH/Health Tracks Health History
|
771 kb
|
5/5/2009
|
Y
|
|
1819
|
Human Services, Department of
|
MCH/Health Tracks Pediatric Assessment
|
558 kb
|
5/5/2009
|
Y
|
|
1992
|
Human Services, Department of
|
Release of Information-Search/Disclosure
|
226 kb
|
|
Y
|
|
2114
|
Financial Institutions, Department of
|
Collection Agency Application
|
67 kb
|
|
N
|
|
2115
|
Financial Institutions, Department of
|
Surety Bond to Operate Collection Agency Business
|
122 kb
|
|
N
|
|
2120
|
Financial Institutions, Department of
|
Money Broker Application
|
67 kb
|
|
N
|
|
2121
|
Financial Institutions, Department of
|
Surety Bond To Operate Money Broker Business
|
122 kb
|
|
N
|
|
2127
|
Financial Institutions, Department of
|
Consumer Finance Application for License
|
64 kb
|
|
N
|
|
2144
|
Financial Institutions, Department of
|
Oath of Trust Officer
|
182 kb
|
8/31/2009
|
Y
|
|
2145
|
Financial Institutions, Department of
|
Oath of Trust Director
|
199 kb
|
9/8/2009
|
Y
|
|
2146
|
Financial Institutions, Department of
|
Oath of Bank Officer
|
182 kb
|
8/31/2009
|
Y
|
|
2147
|
Financial Institutions, Department of
|
Oath of Bank Director
|
199 kb
|
8/31/2009
|
Y
|
|
2148
|
Financial Institutions, Department of
|
Annual Meeting of Stockholders
|
222 kb
|
8/31/2009
|
Y
|
|
2149
|
Financial Institutions, Department of
|
List of Stockholders
|
301 kb
|
8/31/2009
|
Y
|
|
2150
|
Financial Institutions, Department of
|
Annual Report of Examining Committee
|
42 kb
|
|
N
|
|
2242
|
ND Highway Patrol
|
Application for Trooper Employment
|
815 kb
|
2/21/2007
|
Y
|
|
2520
|
Securities Department
|
Dealer-Investment Advisor Indemnity Bond
|
52 kb
|
|
N
|
|
2703
|
Secretary of State
|
Affidavit of Candidacy
|
88 kb
|
|
Y
|
|
2704
|
Secretary of State
|
Petition/Certificate of Nomination
|
740 kb
|
2/6/2008
|
Y
|
|
2706
|
Office of Management and Budget
|
Request for Telephone Quote
|
128 kb
|
|
Y
|
|
2708
|
Office of Management and Budget
|
Request for Faxed Quote
|
57 kb
|
|
Y
|
|
3380
|
Insurance Department
|
Coverage Changes on Current Property Insured
|
63 kb
|
|
Y
|
|
3473
|
Health, Department of
|
Application for Open Burning Variance at Landfills
|
252 kb
|
|
Y
|
|
3850
|
Soil Conservation Commission
|
Annual Budget-Schedule A
|
224 kb
|
7/2/2007
|
Y
|
|
3851
|
Soil Conservation Commission
|
Analysis of Revenue and Expenses-Schedule B
|
246 kb
|
7/2/2007
|
Y
|
|
4598
|
Labor, Department of
|
Employment and Age Certificate
|
75 kb
|
|
N
|
|
4792
|
Insurance Department
|
Date Processing Questionnaire
|
39 kb
|
|
Y
|
|
4795
|
Insurance Department
|
Affidavit
|
167 kb
|
|
Y
|
|
4805
|
Insurance Department
|
County Mutual Abstract of Statement
|
183 kb
|
|
Y
|
|
4818
|
Insurance Department
|
Surplus Line Affidavit
|
189 kb
|
|
Y
|
|
4824
|
Insurance Department
|
Surplus Line Risks
|
286 kb
|
|
Y
|
|
7006
|
Secretary of State
|
Partnership Fictitious Name Certificate
|
160 kb
|
|
Y
|
|
7318
|
Financial Institutions, Department of
|
Employees, Solicitors and Debt Collectors
|
55 kb
|
|
N
|
|
7377
|
Financial Institutions, Department of
|
Annual Report of Loans Made to Manager, Officers, Directors, and Committee Members
|
294 kb
|
8/31/2009
|
Y
|
|
7386
|
Financial Institutions, Department of
|
Application to Expand Field of Membership
|
73 kb
|
|
Y
|
|
7391
|
Financial Institutions, Department of
|
Application to Establish a Branch
|
114 kb
|
|
Y
|
|
7654
|
Secretary of State
|
Lobbyist Expenditure Report
|
332 kb
|
6/9/2009
|
Y
|
|
7672
|
Aeronautics Commission
|
Application For Dealer's License
|
148 kb
|
|
Y
|
|
7832
|
Insurance Department
|
Fire Insurance Premiums and Losses
|
231 kb
|
|
Y
|
|
7936
|
Secretary of State
|
Foreign Limited Partnership Registration
|
163 kb
|
7/28/2008
|
Y
|
|
8330
|
Insurance Department
|
Agent for Service of Process
|
205 kb
|
1/12/2009
|
Y
|
|
8391
|
Health, Department of
|
Transporting Solid Waste-Application for Permit
|
353 kb
|
10/21/2008
|
Y
|
|
8618
|
Health, Department of
|
Client Flow
|
191 kb
|
4/16/2007
|
Y
|
|
8627
|
Health, Department of
|
Medication Profile
|
150 kb
|
4/16/2007
|
Y
|
|
9576
|
Insurance Department
|
Notice of Loss
|
192 kb
|
|
N
|
|
10172
|
Secretary of State
|
Statement of Interests
|
155 kb
|
|
Y
|
|
10230
|
Office of Management and Budget
|
Non-Employee Travel Reimbursement Claim (2009)
|
596 kb
|
8/10/2009
|
Y
|
|
10706
|
Insurance Department
|
Boiler Inspection Report
|
270 kb
|
|
Y
|
|
10920
|
Insurance Department
|
Application for Continuing Education Insurance Course
|
369 kb
|
4/29/2008
|
Y
|
|
10921
|
Insurance Department
|
Application for Continuing Education Provider Coordinator
|
160 kb
|
6/29/2007
|
Y
|
|
10922
|
Insurance Department
|
Course Attendance Roster
|
129 kb
|
|
Y
|
|
10923
|
Insurance Department
|
Continuing Education Course Completion Certificate
|
80 kb
|
|
Y
|
|
10924
|
Insurance Department
|
Continuing Education - Summary Report of Compliance
|
182 kb
|
6/18/2008
|
Y
|
|
10926
|
Insurance Department
|
Notice of Subsequent Offering
|
45 kb
|
|
Y
|
|
11001
|
Secretary of State
|
Notary Application
|
104 kb
|
5/27/2008
|
Y
|
|
11050
|
Insurance Department
|
Reconciled Tax Statement
|
504 kb
|
11/12/2008
|
Y
|
|
11051
|
Insurance Department
|
Estimated Tax Form
|
1101 kb
|
2/3/2009
|
Y
|
|
11106
|
Secretary of State
|
Lobbyist Registration
|
1482 kb
|
6/4/2009
|
Y
|
|
11300
|
Secretary of State
|
Charitable Organization Registration Statement
|
432 kb
|
7/15/2009
|
Y
|
|
11302
|
Secretary of State
|
Charitable Organization Annual Report
|
116 kb
|
7/8/2009
|
Y
|
|
11303
|
Secretary of State
|
Professional Fundraiser Registration
|
147 kb
|
|
Y
|
|
11374
|
Financial Institutions, Department of
|
Report of Annual Audit
|
1866 kb
|
9/23/2009
|
Y
|
|
11375
|
Financial Institutions, Department of
|
List of Directors, Committee Members and Officers
|
331 kb
|
9/23/2009
|
Y
|
|
11501
|
Secretary of State
|
Oath of Office
|
106 kb
|
|
Y
|
|
11516
|
Secretary of State
|
Initiative/Referral/Recall Petition - Statement on Intent of Remuneration
|
702 kb
|
|
N
|
|
11520
|
Secretary of State
|
Campaign Contribution Statement Multi - Candidate Political Committee
|
776 kb
|
|
N
|
|
11601
|
Secretary of State
|
Non-Resident Appointment of Agent
|
140 kb
|
|
N
|
|
11627
|
Aeronautics Commission
|
Application for Registration of Aircraft/Ultralight and Remittance of Excise Tax
|
580 kb
|
7/20/2009
|
Y
|
|
11639
|
Aeronautics Commission
|
Request For State Airport Aid
|
370 kb
|
|
Y
|
|
11700
|
Secretary of State
|
Promoter License Application
|
99 kb
|
7/15/2009
|
N
|
|
11710
|
Secretary of State
|
License Application
|
26 kb
|
6/7/2007
|
N
|
|
11720
|
Secretary of State
|
Professional Boxer/Kickboxer/Mixed Fighting Style License Application
|
221 kb
|
6/7/2007
|
Y
|
|
12012
|
Secretary of State
|
Contractor License Application
|
588 kb
|
7/15/2009
|
Y
|
|
12199
|
Insurance Department
|
Notice of Claim
|
70 kb
|
|
N
|
|
13002
|
Secretary of State
|
North Dakota Professional Corporation Articles of Incorporation
|
327 kb
|
7/16/2008
|
Y
|
|
13003
|
Secretary of State
|
North Dakota Nonprofit Corporation Articles of Incorporation
|
72 kb
|
7/9/2008
|
Y
|
|
13004
|
Secretary of State
|
Business/Professional/Farm Corporation Articles of Dissolution by Incorporators
|
126 kb
|
|
Y
|
|
13005
|
Secretary of State
|
Business/Professional/Farm Corporation Articles of Dissolution
|
115 kb
|
7/28/2008
|
Y
|
|
13006
|
Secretary of State
|
Business/Professional/Farm Corporation Intent to Dissolve
|
139 kb
|
|
Y
|
|
13008
|
Secretary of State
|
Business/Farm/Professional Corporation Articles of Amendment
|
141 kb
|
7/16/2008
|
Y
|
|
13012
|
Secretary of State
|
Nonprofit Corporation Articles of Amendment
|
119 kb
|
7/17/2008
|
Y
|
|
13015
|
Secretary of State
|
Reserve Name Application
|
167 kb
|
|
Y
|
|
13019
|
Secretary of State
|
Registered Agent/Office Statement of Change
|
376 kb
|
9/2/2009
|
Y
|
|
13100
|
Secretary of State
|
Certificate of Authority Foreign Corporation Application
|
520 kb
|
8/11/2008
|
Y
|
|
13101
|
Secretary of State
|
Certificate of Withdrawal Foreign Corporation Application
|
212 kb
|
|
Y
|
|
13107
|
Secretary of State
|
Amended Certificate of Authority Foreign Corporation Application
|
180 kb
|
7/16/2008
|
Y
|
|
13400
|
Secretary of State
|
Trademark/Service Mark Registration
|
199 kb
|
|
Y
|
|
13401
|
Secretary of State
|
Trade Name Registration
|
601 kb
|
9/2/2009
|
Y
|
|
13403
|
Secretary of State
|
Reserve Name Notice Of Transfer
|
147 kb
|
7/28/2008
|
Y
|
|
13408
|
Secretary of State
|
Trademark/Service Mark Assignment
|
147 kb
|
|
Y
|
|
13610
|
Secretary of State
|
Certificate of Professional License
|
120 kb
|
|
Y
|
|
14009
|
Secretary of State
|
UCC Financing Statement Standard UCC-1/CNS-1
|
40 kb
|
9/8/2008
|
N
|
|
14010
|
Secretary of State
|
UCC Standard UCC-3/CNS-3
|
41 kb
|
9/8/2008
|
N
|
|
14529
|
Parks and Recreation
|
Dealer Report: Off-Highway Vehicle & Snowmobile Safety Fee
|
384 kb
|
8/10/2009
|
Y
|
|
14543
|
Labor, Department of
|
Equal Employment Opportunity Questionnaire
|
640 kb
|
7/31/2008
|
Y
|
|
14927
|
Securities Department
|
Complaint Form
|
48 kb
|
|
N
|
|
16259
|
Insurance Department
|
Building Application
|
558 kb
|
5/6/2008
|
Y
|
|
16354
|
Insurance Department
|
Renewal Statement for Admitted Companies
|
275 kb
|
9/29/2008
|
Y
|
|
16812
|
Secretary of State
|
North Dakota Business or Farming Corporation Articles of Incorporation
|
89 kb
|
7/16/2008
|
Y
|
|
16824
|
Insurance Department
|
Annual Statement for an Insurance Premium Finance Company
|
107 kb
|
|
Y
|
|
16825
|
Insurance Department
|
Premium Finance Application
|
296 kb
|
|
Y
|
|
16836
|
Insurance Department
|
Premium Finance Company Balance Sheet
|
270 kb
|
|
Y
|
|
16853
|
Insurance Department
|
Application for Administrator Certificate of Registration
|
192 kb
|
|
Y
|
|
17017
|
Insurance Department
|
Application for Petroleum Tank Release Compensation Fund
|
54 kb
|
|
Y
|
|
17081
|
Labor, Department of
|
Claim for Wages
|
537 kb
|
9/23/2008
|
Y
|
|
17118
|
Insurance Department
|
Medical Malpractice Claim Report
|
145 kb
|
|
Y
|
|
17132
|
Insurance Department
|
Petroleum Tank Registration
|
419 kb
|
10/5/2009
|
Y
|
|
17196
|
Secretary of State
|
Certificate of Endorsement
|
131 kb
|
|
Y
|
|
17331
|
Insurance Department
|
Excavation Expenses Worksheet
|
240 kb
|
|
Y
|
|
17343
|
Secretary of State
|
Voters Affidavit
|
49 kb
|
5/8/2008
|
N
|
|
17419
|
Insurance Department
|
Statement of Taxable Premiums Received on North Dakota Business
|
228 kb
|
2/25/2009
|
Y
|
|
17700
|
Secretary of State
|
Petition to Establish a Political Party
|
31 kb
|
|
N
|
|
17741
|
Secretary of State
|
Agister's Lien/Notice ASL-3
|
35 kb
|
7/23/2008
|
N
|
|
17760
|
Secretary of State
|
Lien/Notice Amendment/Assignment/Termination ASL-4
|
60 kb
|
7/23/2008
|
N
|
|
17818
|
Administrative Hearings, Office of
|
Request For Administrative Law Judge - Complaint
|
269 kb
|
5/8/2009
|
Y
|
|
17819
|
Administrative Hearings, Office of
|
Request For Administrative Law Judge - Appeal, Application, or Petition
|
282 kb
|
5/8/2009
|
Y
|
|
17820
|
Administrative Hearings, Office of
|
Request For Administrative Law Judge - Rules Hearing
|
18 kb
|
5/8/2009
|
Y
|
|
17821
|
Administrative Hearings, Office of
|
Request For Administrative Law Judge - Alternative Dispute Resolution
|
29 kb
|
5/8/2009
|
Y
|
|
17830
|
Secretary of State
|
Real Estate and UCC Filing/UCC-3A
|
39 kb
|
9/8/2008
|
N
|
|
17831
|
Secretary of State
|
UCC Overflow Standard UCC-5/CNS-5
|
33 kb
|
9/8/2008
|
N
|
|
17832
|
Secretary of State
|
Financing Statemetn for Real Estate and UCC Filing/UCC-1A
|
35 kb
|
9/8/2008
|
N
|
|
17899
|
Secretary of State
|
Agricultural Supplier's Lien/Notice ASL-2
|
66 kb
|
7/23/2008
|
N
|
|
17900
|
Secretary of State
|
Agricultural Processor's Lien/Notice ASL-1
|
69 kb
|
7/23/2008
|
N
|
|
17909
|
Secretary of State
|
Political Committee Registration
|
74 kb
|
|
N
|
|
17912
|
Insurance Department
|
Agent of Process-Attachment A
|
42 kb
|
|
Y
|
|
17913
|
Insurance Department
|
Segregated Account/Contents of Contract-Attachment B
|
28 kb
|
|
Y
|
|
17914
|
Insurance Department
|
Application for Certification of Exemption to Issue Gift Annuities
|
55 kb
|
|
Y
|
|
18135
|
Secretary of State
|
Precinct Profile - County and City
|
97 kb
|
|
Y
|
|
18332
|
Insurance Department
|
Utilization Review Filing Report
|
273 kb
|
8/12/2008
|
Y
|
|
18378
|
Insurance Department
|
Utilization Review Agent Certification
|
237 kb
|
1/5/2009
|
Y
|
|
18440
|
Secretary of State
|
Certificate of Write-In Candidacy for President of the US
|
44 kb
|
6/20/2007
|
N
|
|
18556
|
Insurance Department
|
Application for Individual Reinsurance Intermediary License
|
134 kb
|
|
Y
|
|
18687
|
Secretary of State
|
Signature Affidavit Initiated and Referred Measures
|
50 kb
|
|
N
|
|
18731
|
Insurance Department
|
Environmental Consultant Expenses Worksheet
|
382 kb
|
10/22/2007
|
Y
|
|
18739
|
Insurance Department
|
Application for Reinsurance Intermediary License - Corporation or Partnership
|
128 kb
|
|
N
|
|
18857
|
Financial Institutions, Department of
|
Application To Move Main Office Or Facility ("Branch")
|
697 kb
|
|
Y
|
|
18956
|
Insurance Department
|
Complaint Questionnaire
|
231 kb
|
|
Y
|
|
19021
|
Secretary of State
|
Special Write In Absentee Ballot Applications
|
55 kb
|
|
N
|
|
19022
|
Secretary of State
|
Special Write In Absentee Ballot
|
50 kb
|
|
N
|
|
19023
|
Bank of North Dakota
|
ACH Originator Request
|
187 kb
|
9/16/2008
|
Y
|
|
19050
|
Insurance Department
|
Complaint Questionnaire - Agent
|
194 kb
|
|
Y
|
|
19355
|
Secretary of State
|
Notary Bond
|
74 kb
|
5/15/2008
|
Y
|
|
19369
|
Secretary of State
|
Appointment of Agent For Notary Service of Process
|
62 kb
|
|
Y
|
|
19381
|
Secretary of State
|
Certificate of Authority Foreign Limited Liability Company Application
|
171 kb
|
7/17/2008
|
Y
|
|
19433
|
Financial Institutions, Department of
|
Dividend Worksheet
|
188 kb
|
|
Y
|
|
19436
|
Information Tech Dept
|
North Dakota Telecommunications Relay Service Fund Quarterly Surcharge Return
|
290 kb
|
8/26/2009
|
Y
|
|
19445
|
Secretary of State
|
Initial Report for Corporate or Limited Liability Company Farming or Ranching
|
3700 kb
|
7/16/2008
|
Y
|
|
50072
|
Insurance Department
|
Change of Address and/or Name
|
171 kb
|
|
Y
|
|
50144
|
Financial Institutions, Department of
|
Supplement to Statement of Financial Condition
|
204 kb
|
8/31/2009
|
Y
|
|
50233
|
Secretary of State
|
LLP Registration
|
89 kb
|
12/29/2008
|
Y
|
|
50239
|
Secretary of State
|
Professional LLP Registration
|
463 kb
|
7/28/2008
|
Y
|
|
50291
|
Insurance Department
|
Appointment /Termination Form
|
80 kb
|
|
N
|
|
50338
|
Secretary of State
|
Foreign Professional LLP Registration
|
285 kb
|
7/28/2008
|
Y
|
|
50339
|
Secretary of State
|
Foreign LLP Registration
|
985 kb
|
7/9/2009
|
Y
|
|
50443
|
Soil Conservation Commission
|
Annual Budget-Schedule C
|
216 kb
|
7/2/2007
|
Y
|
|
50445
|
Secretary of State
|
Notary Change of Address/Resignation
|
120 kb
|
|
Y
|
|
50469
|
Secretary of State
|
Agricultural Landlord's Lien Notice ASL-5
|
141 kb
|
9/8/2008
|
N
|
|
50470
|
Financial Institutions, Department of
|
Application to Establish a State-Chartered Bank Trust Branch
|
20 kb
|
|
N
|
|
50502
|
Insurance Department
|
Viatical Settlement Provider Individual Statement
|
684 kb
|
10/22/2007
|
Y
|
|
50552
|
Risk Management
|
State Risk Management Fund Notice of Claim
|
66 kb
|
|
Y
|
|
50599
|
Secretary of State
|
Certificate of Write-In Candidacy Statewide, Judicial and Legislative Office
|
174 kb
|
|
N
|
|
50702
|
Financial Institutions, Department of
|
Consumer Complaint
|
299 kb
|
10/21/2008
|
N
|
|
50716
|
Financial Institutions, Department of
|
Brokers
|
48 kb
|
|
N
|
|
50788
|
Financial Institutions, Department of
|
Application to Establish a Facility
|
156 kb
|
|
Y
|
|
50883
|
Secretary of State
|
Certificate of Nomination-Presidential Elector
|
303 kb
|
6/20/2007
|
Y
|
|
50884
|
Insurance Department
|
Sale or Disposal of Petroleum Storage Tanks
|
200 kb
|
5/25/2007
|
Y
|
|
50905
|
Secretary of State
|
Certificate of Nomination-Presidential Electors for Independents
|
29 kb
|
6/20/2007
|
|
