INSTRUCTIONS: CONNECTICUT MUNICIPALITY REPORT OF ABANDONED MOTOR VEHICLE (Form H-109)

When a Connecticut municipality takes possession of an abandoned motor vehicle whose value is $50,000 or less, which is unusable and which does not have a valid marker plate, this is documented using a form H-109. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 1: Section A should be completed when possession of the motor vehicle is taken by the municipality. Enter the name of the municipality in the first blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 2: Enter the date and time the vehicle was taken into custody in the second blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 3: Enter the name of the officer or inspector who evaluated the vehicle in the third blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 4: Enter the badge number of the officer or inspector in the fourth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 5: Enter the year of the vehicle in the fifth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 6: Enter the make of the vehicle in the sixth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 7: Enter the vehicle identification number in the seventh blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 8: Enter the location where the abandoned vehicle was found in the eighth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 9: Enter the business name and address of the tower in the ninth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 10: Enter the amount charged by the tower in the tenth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 11: Enter the department name in the eleventh blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 12: The authorized municipal official should enter their signature in the twelfth blank box and the date in the thirteenth blank box.

Connecticut Municipality Report Of Abandoned Motor Vehicle H-109 Step 13: Section B should be completed when the vehicle has had its ownership transferred to a junkyard.

INSTRUCTIONS: CONNECTICUT APPLICATION FOR WITHHOLDING OF RESIDENT ADDRESS (Form E-224)

Connecticut residents who work in an official capacity for the state use a form E-224 to request that their residential address be withheld from a motor vehicle or vessel license. This document can be obtained from the website of the government of Connecticut.

Connecticut Application For Withholding Of Resident Address E-224 Step 1: Indicate with a check mark whether this application is new, documents a change or if you no longer qualify for withholding of your residential address.

Connecticut Application For Withholding Of Resident Address E-224 Step 2: If this is an application documenting, enter the nature of the change.

Connecticut Application For Withholding Of Resident Address E-224 Step 3: The next section concerns the applicant. Enter the name of your business organization or department in the first blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 4: Enter your date of birth and business email address in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 5: Enter the name of the applicant in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 6: Enter your business telephone number in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 7: Enter your complete business address in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 8: Enter your official title and home phone number in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 9: Enter your residential address in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 10: Indicate your official status with a check mark.

Connecticut Application For Withholding Of Resident Address E-224 Step 11: The next section should be completed by your supervisor, who should enter their name, title, signature, the date and their phone number.

Connecticut Application For Withholding Of Resident Address E-224 Step 12: In the next section, enter all applicable vehicle registration plate numbers and registration classes. If applicable, also enter your vessel registration number.

Connecticut Application For Withholding Of Resident Address E-224 Step 13: At the bottom of the form, enter your signature, operator license number, employee or badge number and the date.

INSTRUCTIONS: CONNECTICUT ORTHOPEDIC MEDICAL REPORT (Form P-142OR)

Connecticut drivers involved in an incident in which an orthopedic incident may have caused an accident may be required to have an examination performed by a medical professional. This examination will be documented using a form P-142OR. This document may be obtained from the website maintained by the government of the state of Connecticut.

Connecticut Orthopedic Medical Report P-142OR Step 1: Enter the date of the incident being addressed at the top right-hand corner.

Connecticut Orthopedic Medical Report P-142OR Step 2: The patient should enter their signature and the date in the first two blank boxes, then give the form to the medical professional for completion.

Connecticut Orthopedic Medical Report P-142OR Step 3: Enter the name of the patient in the first blank box, their date of birth in the second blank box and their telephone number in the third blank box.

Connecticut Orthopedic Medical Report P-142OR Step 4: Enter the patient's address in the fourth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 5: Enter the date of the last examination in the fifth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 6: Indicate with a check mark whether this is a progressive illness. If yes, comment as to its progress.

Connecticut Orthopedic Medical Report P-142OR Step 7: Indicate with a check mark whether there are splints or appliances that should be worn while the patient is operating a motor vehicle. If yes, specify.

Connecticut Orthopedic Medical Report P-142OR Step 8: Indicate with a check mark whether you believe the patient understands the potential risk posed by their condition which may affect their ability to operate a motor vehicle. 

Connecticut Orthopedic Medical Report P-142OR Step 9: Indicate with a check mark whether you believe the patient takes medications as prescribed.

Connecticut Orthopedic Medical Report P-142OR Step 10: In the blank space provided, write any abnormalities detected during the orthopedic examination. Indicate with a check mark whether there are any other conditions that should be evaluated by another specialist. If so, provide an explanation.

Connecticut Orthopedic Medical Report P-142OR Step 11: Answer the next four questions by checking "yes" or "no" as appropriate. In response to the last question, indicate what types of restrictions would make it appropriate for the patient to operate a vehicle safely. Sign and date the form and provide all identifying information requested.

INSTRUCTIONS: ALABAMA VERIFICATION OF LICENSURE 

This article discusses the form used to verify an Alabama license issued to a professional engineer in the state. This document can be obtained from the website maintained by the Alabama Board of Licensure for Professional Engineers & Land Surveyors.

Alabama Verification Of Licensure Step 1: In the first shaded area, enter the State Board address.

Alabama Verification Of Licensure Step 2: In the second area, enter your name and address.

Alabama Verification Of Licensure Step 3: In the third shaded area, enter the deadline date listed on the website of the Alabama Board of Licensure for Professional Engineers & Land Surveyors.

Alabama Verification Of Licensure Step 4: In the fourth shaded area, enter your social Security number.

Alabama Verification Of Licensure Step 5: Section I concerns the type of license you were issued. Check the first statement if you were issued an Engineer Intern license and enter the license number in the first column.

Alabama Verification Of Licensure Step 6: Check the second statement if you were issued a Professional Engineer license and enter the license number in the first column.

Alabama Verification Of Licensure Step 7: Check the third statement if you were issued a Land Surveyor Intern license and enter the license number in the first column.

Alabama Verification Of Licensure Step 8: Check the fourth statement if you were issued a Professional Land Surveyor license and enter the license number in the first column.

Alabama Verification Of Licensure Step 9: Mail the form to the address given at the top of the page. The remainder of the form will be completed by a member of the Alabama Board of Licensure for Professional Engineers and Land Surveyors. Before mailing, you should check the board to see if a fee is required.

Alabama Verification Of Licensure Step 10: In Section I, the board will enter the date the applicable license was issued in the second column and the until which it is valid in the third column.

Alabama Verification Of Licensure Step 11: In Section II, the board will enter the basis of the licensure.

Alabama Verification Of Licensure Step 12: In Section III, the board will note whether you have ever been disciplined by them or whether disciplinary action is pending. The official completing the form will then sign the bottom and enter their title and the date.

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL (FPL) DISCOUNT APPLICATION (Form IB12)

To apply for a discount on Alabama state employees' insurance on the basis of being at or below the federal poverty level, file a form IB12. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 1: Part 1 concerns the employee or retiree. Enter your first, middle and last name in the first blank box and your contract number in the second blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 2: Enter your street address in the third blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 3: Enter your city, state and zip code in the fourth blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 4: Enter your home phone number in the fifth blank box, your work phone number in the sixth blank box, and your cell phone number in the seventh blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 5: Indicate your marital status by circling "Single" or "Married" in the eighth box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 6: Enter your email address in the ninth blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 7: Part 2 concerns your household income. Document household income from all sources listed on lines 1 through 21 of the table provided.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 8: The table provided below is for documentation of household members receiving income. Enter their name in the first column, their source of income in the second column, the current gross monthly amount in the third column, and the projected annual gross amount in the fourth column.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 9: Document all household members in Part 3. Enter their name in the first column, Social Security number in the second column, their relationship to the state employee in the third column, their date of birth in the fourth column, their age in the fifth column and their sex in the sixth column.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 10: In Part 4, enter your signature on the first blank line and the date on the second blank line.

INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT STATUS CHANGE (Form PEEHIP FSA Change)

To document a change in your status as an Alabama public employee enrolled in a flexible spending account administered by BlueCross BlueShield, use a PEEHIP FSA change form. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 1: The first section concerns the subscriber. In the first four blank boxes, enter your Social Security number or PID number, first name, middle name or initial and last name.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 2: In the next four blank boxes, enter your mailing street address, city, state and zip code.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 3: In the next blank box, enter your date of birth.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 4: In the next two blank boxes, enter your home and work phone numbers.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 5: In the next blank box, enter your email address.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 6: Indicate whether you are single, married, divorced, legally separated or widowed with a check mark.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 7: The next reason concerns your reason for the status change. Indicate this with a check mark next to the applicable statement.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 8: Enter the date on which the qualifying event occurred.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 9: The next section concerns your flexible spending account. If making a new annual election amount, check the box where indicated. Enter the monthly and annual amounts.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 10: Check the second box if you wish to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 11: The next section concerns dependant care flexible spending accounts. Indicate with a check mark if you wish to make a new annual election amount or to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 12: Sign and date the form where indicated.