SFN 446, "Request to Claim 'Good Cause" 510-03-100-45

(New 7/1/2014 ML #3404)

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The form provides the caretaker with the opportunity to describe the circumstances which he/she believes will have a bearing on the claim.

 

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms. (44 kb pdf)

 

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.