Form KDOC-0064 "Kdoc Trust Fund Reimbursement / Withdrawal Request" - Kansas

What Is Form KDOC-0064?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the Kansas Department of Corrections;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form KDOC-0064 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

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Download Form KDOC-0064 "Kdoc Trust Fund Reimbursement / Withdrawal Request" - Kansas

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KDOC Trust Fund Reimbursement / Withdrawal Request
Community Supervision Agency Information
Requesting Agency:
Mailing Address:
Community Supervision Officer:
Telephone Number:
Juvenile Information
Name:
DOB:
IV-E Eligible?
Yes
No
SSN:
Benefit Type:
Current Placement:
Start
Date:
Placement History (Please indicate each placement type this Juvenile has lived in for the last 2 years.):
Juvenile Correctional Facility?
Yes
No
If yes,
From
To:
provide
dates:
Psychiatric Residential Treatment Facility (PRTF) or Medicaid Billable placement?
Yes
No
Non-PRTF Out of Home Placement or other placements that are not Medicaid Billable?
Yes
No
Other, ple se explain:
a
Type of Purchase or Expense:
Date of Purchase:
Attached Verification
(Mark all that apply with an X.)
Attach copies
Bill or
Receipt(s)
Voucher
Local Agency
of:
Invoice
Check
Other: (please specify)
Community Supervision Agency Approval
Date:
Signature of Agency Director or Designee:
Title: Community Supervision Officer
KDOC Decision
(For KDOC use only)
Reimbursement approved.
Reimbursement check in the amount of
Enclosed.
_________
_____________
_
___
____________________________________
________
___
Withdrawal approved.
Withdrawal check in the amount of
Enclosed.
Reimbursement denied.
Reason for denial
________________________
___
Withdrawal denied.
Signature:
Title:
Date:
Submit to: KDOC  714 SW Jackson, Ste. 300  Topeka, KS. 66603
KDOC-0064
Revised July 2007
KDOC Trust Fund Reimbursement / Withdrawal Request
Community Supervision Agency Information
Requesting Agency:
Mailing Address:
Community Supervision Officer:
Telephone Number:
Juvenile Information
Name:
DOB:
IV-E Eligible?
Yes
No
SSN:
Benefit Type:
Current Placement:
Start
Date:
Placement History (Please indicate each placement type this Juvenile has lived in for the last 2 years.):
Juvenile Correctional Facility?
Yes
No
If yes,
From
To:
provide
dates:
Psychiatric Residential Treatment Facility (PRTF) or Medicaid Billable placement?
Yes
No
Non-PRTF Out of Home Placement or other placements that are not Medicaid Billable?
Yes
No
Other, ple se explain:
a
Type of Purchase or Expense:
Date of Purchase:
Attached Verification
(Mark all that apply with an X.)
Attach copies
Bill or
Receipt(s)
Voucher
Local Agency
of:
Invoice
Check
Other: (please specify)
Community Supervision Agency Approval
Date:
Signature of Agency Director or Designee:
Title: Community Supervision Officer
KDOC Decision
(For KDOC use only)
Reimbursement approved.
Reimbursement check in the amount of
Enclosed.
_________
_____________
_
___
____________________________________
________
___
Withdrawal approved.
Withdrawal check in the amount of
Enclosed.
Reimbursement denied.
Reason for denial
________________________
___
Withdrawal denied.
Signature:
Title:
Date:
Submit to: KDOC  714 SW Jackson, Ste. 300  Topeka, KS. 66603
KDOC-0064
Revised July 2007