Notice of Assignment
Document Number: DCF-F-DWSP2477
Description: This is a Multiple Program Form. This form is for W-2 and Medicaid program participants. The participant acknowledges the assignment by signing the form. If the participant refuses to acknowledge the assignment, the agency representative is to sign the gray shaded box which indicates the participant's refusal to acknowledge the assignment.
DCF-F-DWSP2477 (English Print Version - pdf/20 KB)
DCF-F-DWSP2477-H (Hmong Print Version - pdf/21 KB)
DCF-F-DWSP2477-S (Spanish Print Version - pdf/19 KB)
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